Blueberry Hill Rehabilitation and Healthcare Ctr

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, 1. For Resident #134 who was diagnosed with Influenza Type A, the facility failed to ensure staff implemented precautions after entering and exiting a room identified as being on contact precautions.2. Failed to, ensure nursing staff disinfected a blood glucose monitor after use.3. Failed to, ensure nursing staff performed hand hygiene appropriately during the medication administration task.

Inspectors wroteBased on record review and interview, the facility failed to ensure it reported an allegation of abuse to the state agency for one Resident (#18) of 36 sampled residents.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for one Resident (#9) out of a total sample of 36 residents. Specifically, for Resident #9, the facility failed to develop a psychotropic medication care plan.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to meet professional standards of practice for three Residents (#7, #8, and #34) out of a total sample of 36 residents. Specifically: the facility failed to implement physician orders for insulin administration prior to the breakfast meal.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide behavioral health services for one Resident (#35) out of a total of 36 sampled Residents. Specifically, for Resident #35, the facility failed to a. ensure Resident #35 was seen by behavioral health services timely, and b. failed to implement medication change recommendations by the psychiatric Nurse Practitioner timely.

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, the facility failed to 1.ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, when two insulin pens were observed unlabeled during the medication pass observation and 2. failed to ensure staff secured medications as evidenced by leaving a syringe with insulin unattended on top of a medication cart on the [NAME] unit.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure follow-up dental services were provided for one Resident (#121) out of a total of 36 sampled residents. Specifically, the facility failed to ensure Resident #121 received dental exams every six months as recommended by the dentist.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 12/25/24, Resident #1 was administered his/her scheduled medications in the morning by his/her assigned nurse and then Nurse #1, administered another resident's medications to Resident #1 in error. Several hours later Resident #1 experienced a significant change in condition, was disoriented and became lethargic, was transferred to the Hospital Emergency Department (ED), and was admitted to the Hospital for four days due to an accidental drug overdose.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure they notified his/her medical provider of a medication incident, when on 12/25/24, his/her morning medications were administered well over one hour later than the prescribed times, and his/her scheduled morning and afternoon Clonazepam (antipsychotic) doses were administered at the same time.

Inspectors wrote2. Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: - Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/ mental condition and or status (e.g. changes in level of care, billing/ payments, resident rights etc.) - 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (situation, background, assessment, recommendation) Communication Form. - 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant change in a resident's status for one Resident (#24) out of a total sample of 39 residents. Specifically, for Resident #24, the facility failed to provide a covering Nurse Practitioner (NP) with complete and accurate information about a resident with coffee ground emesis and ongoing black stools, including but not limited to the Resident's significant history of bowel obstructions and Gastrointestinal (GI) bleeding, resulting in hospitalization and subsequent death. Findings Include: Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to protect two Residents (#24 and #323), from neglect, out of a total sample of 39 residents. Specifically, 1. For Resident #24, the facility neglected to monitor, assess and notify the physician timely for the Resident who was found to be vomiting coffee ground emesis and exhibiting continuous stooling of black liquid. 2. For Resident #323, the facility neglected to a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician and/or delegate supervision after a change in medical status for one Resident (#323) of a total sample of 39 residents. Specifically, the facility failed to follow up on abnormal labs that were drawn, for a Resident with a known history of Chronic Kidney Disease, resulting in critically high labs, which required emergency hospitalization and death.

Inspectors wrote2. For Resident #110 the facility failed to implement a treatment for a pressure ulcer identified on 10/18/24. Resident #110 was admitted to the facility in April 2024 with diagnoses including unspecified dementia, muscle wasting and atrophy, and moderate-protein calorie malnutrition, Review of the Minimum Data Set assessment, dated 10/23/24, indicated a staff assessment for mental status was completed and indicated Resident #110 as having severely impaired cognition. Further the MDS indicated Resident #110 is dependent on staff for toileting and bathing, is at risk for developing pressure ulcers and had one stage 2 pressure ulcer not present on admission or reentry. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain acceptable nutrition status for three Residents (#114, #323, and #74) out of a total sample of 39 residents. Specifically, 1. For Resident #114 the facility failed to; a. failed to identify and address significant weight loss and b. failed to provide fortified foods in accordance with physician's orders following a significant weight loss. 2. For Resident #323, the facility failed to identify and address a significant weight loss. 3. For Resident #74, the facility failed to identify and address a significant weight loss timely. Findings Include: Review of facility policy titled Weight Assessment and Intervention, undated, indicated the following: -Resident weights are monitored for undesirable or unintended weight loss or gain. -1. [...]

Inspectors wroteBased on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring with measurable outcomes for a pressure ulcer QAPI project. Findings Include: During the survey period, multiple residents were identified as having facility acquired pressure ulcers with delayed treatment. During an interview on 11/7/24 at 10:41 A.M., the Administrator and Director of Nursing said they had recently developed a QAPI project for skin as it was identified as an area of concern for the building. The Administrator and Director of Nursing said the project's goal was to lessen the frequency of facility acquired pressure ulcers and the facility used reports to measure the progress of the project. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure six Residents (#41, #43, #73, #87, #61 and #19) were provided a dignified existence and were able to exercise their rights as residents of the facility, out of a total of 39 sampled residents. Specifically; 1. For Resident #41, Resident #43, Resident #73, and Resident #87 the facility failed to ensure mail in ballots were obtained and submitted for the 11/5/24 Presidential election. 2. For Resident #61, the facility failed to respect the Residents right to self determination when he/she expressed interest in being intimate with his/her spouse. 3. For Resident #19, the facility failed to ensure a dignified dining experience when staff stood over the Resident while assisting with meals.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement personalized care plans for four Residents (#91, #106, #117, and #323), out of a total sample of 39 residents. Specifically: 1. For Resident #91, the facility failed to develop a care plan for suicide ideation, 2. For Resident #106, the facility failed to develop a skin at risk care plan, 3. For Resident #117, the facility failed to implement a care plan for a pacemaker. 4. For Resident #323, the facility failed to implement a plan of care for skin checks.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of practice for 12 Residents (#40, #47, #41, #92, #108, #4, #55, #12, #19, #106, #2 and #75) out of a total of 39 sampled residents. Specifically: 1. For Resident #40, the facility failed to a.) obtain a physicians order for the treatment of a skin tear and b.) failed to complete weekly skin checks as ordered. 2. For Resident #47, the facility failed to complete weekly skin checks as ordered. 3. For Resident #41, the facility failed to complete weekly skin checks as ordered. 4. For Resident #92, the facility failed to complete weekly skin checks as ordered. 5. For Resident #108, the facility failed to complete weekly skin checks as ordered. 6. For Resident #4, the facility failed to to complete weekly skin checks as ordered. 7. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide a person-centered activity program for four Residents (#25, #103, #87, and #28) out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure sufficient staffing to assure that residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for Fiscal Year Quarter 3 2024 (April 1 - June 30)

Inspectors wroteBased on record review and interviews, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for two Residents (#91, #4) out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide dental services for four Residents (#28, #103, #18 and #111), out of a total sample of 39 residents. Specifically, 1. For Resident #111, the facility failed to follow-up with a recommendation from the dentist to have teeth extracted. 2. For Resident #18, the facility failed to make a dental appointment to ensure his/her dentures fit appropriately, 3. For Resident #28, the facility failed to have the Resident seen by the contracted dentist for over two years after the consulting dentist made the recommendation for new dentures, and 4. For Resident #103, the facility failed to have the Resident seen by the dentist since admit to the facility

Inspectors wroteBased on observation and test trays, the facility failed to provide food at a safe and palatable temperature for 2 out of 3 test trays.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure nursing staff documented accurately in the medical record for two Residents (#37 and #65) out of a total sample of 39 Residents. Specifically, 1. For Resident #37, the facility failed to ensure nursing staff accurately documented an orthotic device was worn as ordered. 2. For Resident #65, the facility failed to ensure nursing staff accurately documented which arm a blood pressure was taken.

Inspectors wrote3. On 11/5/24 at 7:33 A.M. and 7:40 A.M., the surveyor observed the Wound Physician and Nurse #5 enter a resident's room with a posted Enhanced Barrier Precaution (EBP) sign and provided wound care with out PPE on. During an interview on 11/5/24 at 7:44 A.M., the Wound Physician and Nurse #5 said they did wound rounds on each of the Resident's but did not apply Personal Protective Equipment (PPE) as they thought it was only for bigger wounds. During an interview on 11/7/24 at 8:00 A.M., the Regional Nurse said PPE should be applied during all wound care. Based on observation, interview, record review, and policy review the facility failed to 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. Specifically, 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to 1a. assess decision-making capacity and 1b. obtain consent for a psychotropic medication for one Resident (#323), out of a total sample of 39 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#111) was allowed to participate in the care planning process, out of a total sample of 39 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one Resident (#18) with the right to alternate the position of his/her bed independently, out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a clean, homelike environment on one out of three resident care units. Specifically, the Hale Unit had lingering, stale urine odors in the hallway.

Inspectors wroteBased on observation, record review, and interview, the facility failed to investigate an allegation of potential neglect for one Resident (#25) out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide supervision during meals for two Residents (#92 and #18) out of a total of 39 sampled residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an orthotic device was worn as ordered for one Resident (#37) out of a total sample of 39 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#19) out of a total sample of 39 residents. Specifically, for Resident #19, the facility failed to ensure his/her oxygen concentrator air filter was in place. Findings Include: Resident #19 was admitted to the facility September 2024 with diagnoses that include acute respiratory failure with hypoxia and aspiration. Review of Resident #19's most recent Minimum Data Set (MDS) Assessment, dated as 10/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated the use of oxygen. The surveyor made the following observations: -On 11/3/24 at 7:38 A.M. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one Resident (#39) out of a total sample of 39 residents. Specifically, for Resident #39 the facility failed to administer scheduled pain medications timely in accordance with physician's orders. Findings Include: Review of facility policy titled Pain Assessment and Management, dated as revised October 2022, indicated the following: - The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a person-centered plan of care was developed for Trauma-Informed Care for one Resident (#4), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that the nursing staff demonstrated appropriate competencies, and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure that 3 licensed nurses (#5, #6, and #9), two who were on the schedule during the survey, and one recently on the schedule on 11/2/24, out of a total of six nursing employee records reviewed, had nursing competency evaluations.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed by the facility in a timely manner for two Residents (#55 and #117), out of a total sample of 39 Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident's (#75) medication regime was free from unnecessary medications, out of a total sample of 39 residents. Specifically, the facility failed to adhere to the physician's ordered parameters and administered insulin when Resident #75's blood sugar was below 100.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all medications used in the facility were stored in accordance with accepted professional principles of practice on two out of three units. Specifically, 1. The facility failed to ensure nursing staff secured medications while not present at his/her medication cart, 2. The facility failed to ensure nursing staff secured the treatment cart during wound rounds, 3. The facility failed to secure antifugnal cream which was left in Resident #2's room.

Inspectors wroteBased on record review and interview, the facility failed to provide the appropriate diet texture for one Resident (#323) out of a total sample of 39 residents. Specifically, Resident #323 was given a soft cookie while being prescribed a puree diet.

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to include, in writing, the reason for the transfer/discharge to the hospital, on the Notice of Intent to Transfer/Discharge, that was sent to the residents representatives, as required.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services for two Residents (#37 and #52) out of a total sample of 31 residents that resulted in mental anguish and psychological distress. Specifically: 1. For Resident #37, the facility failed to follow up on the Resident's voiced side effect concerns and schedule an eye specialist appointment as recommended by the optometrist which resulted in psychological harm and mental anguish. 2. For Resident #52, the facility failed to provide bladder incontinence care which resulted in the Resident experiencing psychological distress leading to suicidal ideations.

Inspectors wroteBased on interviews and records reviewed for one Resident (#81) of 31 sampled residents, the facility failed to implement falls care plans. Specifically: 1) for Resident # 81, the facility failed to provide supervision per the fall care plan resulting in a fall with a hand fracture.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Findings Include: Review of the facility assessment, undated, indicated the following: Staffing Guidelines *Our facility has created a staffing pattern to ensure that our residents's needs are met on a consistent basis. Our staffing patterns provide a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of Massachusetts' regulatory requirements for minimum number of hours of care per resident day (PPD) of 3.58 hours (of which at least 0.508 hours must be care provided by a registered nurse into our staffing baseline. [...]

Inspectors wroteBased on interview, policy review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for five out of five certified nursing assistants (CNAs), and three out of three licensed nurses whose education records were reviewed.

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

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure hairnets were worn in the food preparation area, food was labeled, that food was not cooked below a possible contaminate, and that ready to eat food was not contaminated by the handle of serving tongs.

Inspectors wroteBased on interviews and policy review, the Facility failed to have the Medical Director actively involved in the antibiotic stewardship program.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on record review policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for five of five Certified Nurse Aides (CNAs).

Inspectors wroteBased on observation and interview, the facility failed to maintain a home-like environment on two of three resident units.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement and develop care plans for 7 Residents, # 37, #222, #52, #75, #272 #19 and #65 out of a sample of 31 residents. Specifically, 1. For Resident #37, the facility failed to develop a mood and behavior care plan, 2. For Resident #222, the facility failed to develop a behavior care plan, 3. For Resident #52, the facility failed to develop a mood and behavior care plan. 4. For Resident #75, the facility failed to implement fall interventions as indicated in his/her care plan. Specifically, the facility failed to: (a) administer a helmet at all times as indicated in the physician's orders, (b) implement two floor mats and maintain the bed in a low position as indicated in the care plan. 5. [...]

Inspectors wrote3. Resident #16 was admitted to the facility in September 2019 with diagnoses including dysphagia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 indicating severe impairment. During observations on 10/22/23 at 8:40 A.M., 10/24/23 at 7:58 A.M., and 10/5/23 at 8:03 A.M., Resident #16 was observed eating breakfast alone in bed. A review of the Resident's October 2023 physician's orders indicated the following: *I require staff assistance with eating meals A review of the ADL care plan initiated 5/10/23 indicated the following: *Eating: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure 1.) the medication carts and treatment carts were secured on 1 of 3 nursing units, 2.) inhalers and insulin were dated when opened in 3 of 3 medication carts observed and 3.) poured medications were disposed of properly after a resident refused the medications.

Inspectors wroteBased on observation, record review and interview the facility failed to provide the prescribed therapeutic diet for 3 Residents (#19, #81, and #37) out of a total of 31 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education regarding vaccine refusals, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#48 and #76) out of a total of 5 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#25) out of a sample of 31 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on 2 of 3 nursing units.

Inspectors wroteBased on record review and interview, the facility failed to report a bruise of unknown origin for 1 Resident (#81) out of a total sample of 31 residents.

Inspectors wroteBased on record review and interview, the facility failed to investigate a bruise of unknown origin for 1 Resident (#81) out of a total sample of 31 residents.

Inspectors wroteBased on interview and record review the facility failed to revise and update an Activities of Daily Living (ADL) care plan after a change in status for 1 Resident (#19) out of a total sample of 31 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement a language communication care plan for one Resident (#16) out of a sample of 31 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) was provided in accordance of professional standards of practice and his/her physician's orders for two Residents (#89, and #39), out of a total sample of 31 residents. Specifically, 1(a) For Resident #89, the facility failed to cap the gastronomy tube (G-tube), (b) For Resident #89, the facility failed to follow the G-tube feeding orders, 2. For Resident #39, the facility failed to implement G-tube flushing per the physician's orders.

Inspectors wroteBased on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to change and clean the oxygen filters for one Resident (#89) out of a total sample 31 residents.

Inspectors wroteBased on interview and record review, the facility failed to review pharmacist recommendations for two Residents (#66 and #81) out of a total sample of 31 residents.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of three nurses observed made two errors out of 30 opportunities, resulting in a medication error rate of 6.67 %. Those errors impacted one Resident (#3), out of seven residents observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate dental services for 1 Resident (#19) out of a total of 31 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for three Residents (#75, #222 and #89) out of a total sample of 31 residents. Specifically, for Residents #75, and #89 nursing failed to accurately document in the Medication Administration Record. For Resident #222, nursing failed to document accurately in the physician's orders. Findings Include: 1. Resident #75 was admitted to the facility in August 2020 with diagnoses including seizure disorder related to a head injury. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 9 out of a possible 15 indicating moderate impairment. A review of Resident #75's October 2023 physicians orders indicated the following: *Always ensure resident wears helmet every shift. [...]

Inspectors wroteBased on observation, interview and policy reviews, the facility failed to ensure nursing staff maintained infection control practices during medication administration pass on 2 of 3 units.