Brockton Post Acute Care

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure nursing provided care and services that met professional standards of practice, when upon admission his/her medications were not reconciled accurately, and medications were administered at doses and intervals that were not consistent with Physicians Orders.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure appropriate treatment and services were provided to maintain or improve his or her ability to carry out the activities of daily living and attain or maintain the highest practical physical, mental, and psychosocial well-being for two Residents (#37 and #38 out of a sample of 27 residents. Specifically, the facility failed to ensure: 1. For Resident #37 with a diagnosis of Aphasia (communication disorder that affects speech, writing and language understanding) was assessed for communication 2. For Resident #12 to ensure Speech Therapy (SLP) evaluation was completed timely after admission and to ensure Physical Therapy (PT) visits were completed per physician order/plan of care. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop and consistently implement effective interventions to prevent four unwitnessed falls, resulting in three injuries on 11/2/24, 11/30/24 and 1/26/25, for one Resident (#16), out of a total sample of 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Residents (#29) with a history of trauma, out of a total sample of 27 residents.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were implemented to ensure that emergency Kits were replaced timely. Five out of five drawers of Supper Kit #51001 were impacted and 1of 1 Cubex Kit was also impacted. Specifically, the facility failed to ensure that emergency medication kits (E-Kits) were re-ordered and replaced timely by the Pharmacy after being opened. Findings Include: Review of the facility Pharmacy policy titled Emergency Medication dated April 2025, indicated but was not limited to the following: [...]

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to provide food to residents that was served at appetizing temperatures for one of two test trays.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of one Resident (#16), out of a sample of 27 residents. Specifically, the facility failed to ensure an MDS was accurately coded for a fall with injury.

Inspectors wroteBased on records reviewed and interviews for one of three sampled resident (Resident #1), the Facility failed to ensure that the resident and/or his/her family member or legal representative participated in the development and implementation of their person-center care plans, which included conducting and inviting the resident and/or their legal representative to an interdisciplinary care plan meeting following the completion of any Comprehensive Minimum Data Set (MDS) Assessment, including the Admission, Quarterly, and Annual MDS.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was alert, oriented and his/her own decision maker, the facility failed to ensure Resident #1 and/or his/her Representative were provided with a written explanation of the need to change his/her room, when on 06/26/24 Resident #1's was moved to a new room despite his/her wishes to remain in his/her original room.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had been admitted with three pressure injuries, the Facility failed to ensure they maintained complete and accurate medical/clinical records including but not limited to documentation related to the completion and accuracy of skin assessments.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure, for four Residents (#336, #110, #25, and #100), out of a total sample of 24 residents, the right to personal privacy of his/her own physical body during medical treatment was maintained.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided with an environment which was free from accident hazards on two (Arborwood and Cedarwood) of three units in the facility. Specifically, the facility failed to ensure potentially hazardous items were not left unsecured and easily accessible to residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required on three of three units in the facility. Specifically, the facility failed to: 1. Ensure all medication and treatment carts were locked when unattended and unsupervised; and 2. Provide separately locked, permanently affixed compartments for storage of controlled substances.

Inspectors wroteBased on observation and interviews, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for one of two test trays.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was maintained in a sanitary condition; 2. Ensure all food items were properly labeled and dated in the main kitchen refrigerators; 3. Ensure the food/drinks stored in the reach-in single door refrigerator maintained a safe temperature of below 41 degrees Fahrenheit (F); 4. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; 5. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the residents and/or their representatives were informed and given necessary information to make health care decisions, including the risks and benefits of psychotropic medications and obtain consent for their use, prior to administration for one Resident (#57), out of total sample of 24 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for two Residents (#100 and #235), in a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #100, a baseline care plan was developed for the Resident's dialysis treatment; and 2. For Resident #235, a baseline care plan was developed for the Resident's cardiac pacemaker (an implanted medical device used to control an irregular heart rhythm).

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for two Residents (#48, #235), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #48, a. To ensure a physician's order was obtained prior to collecting a urine sample via straight catheterization (removing urine from the bladder by placing a tube into the bladder), and b. To notify a physician or nurse practitioner (NP) of an abnormal urinalysis result in a timely manner to avoid a three-day delay in administering antibiotics for a urinary tract infection (UTI); and 2. For Resident #235, to monitor for signs/symptoms for pacemaker complications, monitor the function of the pacemaker, and document the model, make, and date of insertion per facility policy from admission until 12/23/23.

Inspectors wroteBased on records reviewed and interviews, for two Residents (#100 and #336), from a sample of 24 residents, the facility failed to ensure complete and accurate medical records were maintained according to professional standards of practice related to documentation of critically high laboratory testing results.

Inspectors wroteBased on interviews and records reviewed, for two Residents (#89 and #107), of six residents reviewed, the facility failed to conduct significant change comprehensive assessments through completion of Minimum Data Set (MDS) assessments as required.

Inspectors wroteBased on interviews and records reviewed, for two Residents (#86 and #235), of six residents reviewed and 24 sampled residents, the facility failed to conduct quarterly assessments through completion of Minimum Data Set (MDS) assessments as required.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure an MDS assessment was completed timely as required for three Residents (#77, #5, and #78), out of six records reviewed and 24 sampled residents. Specifically, the facility failed to ensure completion of an MDS discharge assessment within the required timeframe.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for two Residents (#4 and #100), in a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #4, to ensure the MDS accurately reflected his/her preferences for customary routine and activities; and 2. For Resident #100, to ensure the MDS accurately reflected his/her dialysis status.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to properly store and label food in the facility kitchen and on two out of three unit nourishment kitchens in accordance with professional standards of practice to ensure food safety. Specifically, the facility failed to: 1. properly label and store food items in the dry storage room and kitchen refrigerators, 2. ensure food was properly stored in the kitchen freezer to allow for circulation, 3. properly label resident food in two out of three unit nourishment kitchens, and 4. ensure staff followed the facility's policy for storage of personal food items.

Inspectors wroteBased on a resident group meeting, staff interviews and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding residents feeling they were not being treated respectfully, were acted upon timely.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure staff developed an individualized comprehensive care plan 3 Residents (#43, #58, #30), out of a total sample of 25 Residents. Specifically, the facility failed to: 1. for Resident #43, develop a care plan for a midline catheter and transmission-based precautions (TBP), 2. for Resident #58, develop a care plan for the management of the Resident's chronic obstructive pulmonary disease (COPD), including the use of nebulizer treatments, and 3. for Resident #30, develop a care plan for mobility care needs.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and the facility policy.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure standards of practice were followed for infection control practices. Specifically, the facility failed to: 1. limit the movement and prioritize cleaning and disinfection for a Resident (#43) on contact precautions for extended spectrum beta lactamase (ESBL) (bacterial infection resistant to many antibiotics), 2. ensure staff wore the appropriate personal protective equipment (PPE) in the facility kitchen and in patient care areas, and 3. perform proper hand hygiene during a Resident's (#30) dressing change.

Inspectors wroteBased on interview, record review and policy review the facility failed to determine the competency of the Resident to self administer medication, for 1 Resident (#93) out of a total sample of 25 Residents.

Inspectors wroteBased on record review and interview, the facility failed to conduct an interview with the responsible party to ensure that a timely activity comprehensive assessment was completed for one Resident (# 86) out of a total of 25 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a PICC line dressing was dated and maintained in accordance with the current physician orders for one Resident (#93), out of a total sample of 25 Residents.

Inspectors wroteBased on observation and interview the facility failed to maintain the nebulizer tubing and set up for one Resident (#58) out of a total sample of 25 residents.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure that all electrical equipment on one of three unit nourishment kitchens were maintained and in safe operating condition.