Cabot Health and Rehab, LLC

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined the facility failed to ensure that the resident's transfer or discharge was reported to the ombudsman for two (Resident #75 and Resident #77) of two residents reviewed.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined that the facility failed to prepare, distribute, and serve food under sanitary conditions. Specifically, the facility failed to ensure that dietary staff performed hand hygiene in between tasks for three (3) of three (3) staff (Dietary Aide #1, Dietary Aide #2 and Cook) observed in the kitchen.

Inspectors wroteBased on record review, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #52) of 8 sample mix residents.

Inspectors wroteBased on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 6 (Residents #52, #38, #60, #3, #44, and #377) of 15 sample mix residents reviewed for care plan.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet during one (1) of one (1) meal service observed.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure the survey inspection book was kept in a place where residents and family members could reach the book without asking.

Inspectors wroteBased on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) within 14 calendar days after admission to identify issues needed for comprehensive care plan development for 1 (Resident #52) of 8 sample mix residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure resident Care Plan meetings were attempted every quarter for one (Resident #38) of one resident reviewed for Care Plan meetings.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to remove facial hair for 1 (Resident #69) of 4 sampled residents reviewed for activities of daily living.

Inspectors wroteBased on interview and record review it was determined that the facility failed to carry out interventions after a fall for 1 (Resident #2) of 4 sampled residents reviewed for falls.

Inspectors wroteBased on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure that an accurate Physician ' s Order was in place for oxygen for 1 (Resident #52) of 1 sample mix residents who received oxygen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure leftover food items were discarded to maintain food quality; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; failed to properly clean and sanitize food thermometer between raw ground meat and cooked meat; failed to properly store frozen raw beef in freezer to prevent cross contamination; failed to removed expired food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that 2 Residents (Resident #26 and #320) were properly clothed and covered in common areas. This failed practice was a violation of res resident's right to have dignity.

Inspectors wroteBased on record review and interview, the facility failed to accurately record on the resident assessment to ensure the Minimum Data Set [MDS] accurately reflected section for special treatments, procedures, and programs including oxygen to facilitate the ability to plan, coordinate, and provide necessary care for 1 (Resident #23) of 6 Sample Residents (R#2, R#23, R#39, R#53, R#55, R#64) receiving oxygen therapy. The facility failed to have a procedure in place to monitor activities of daily living [ADL] decline in Residents. The facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1 (Resident #31) of 1 sampled resident requiring a level II PASARR.

Inspectors wroteBased on observation, record review and interview, the facility to ensure the environment was free of potential accident hazards by failure to ensure manufacture guidelines were followed when using a lift for transfer assistance affecting 1 (Resident #25) of 6 sampled (Residents #10 #25, #31, #32, #35, #46) requiring a lift for transfer assistance. The facility failed to ensure interventions were implemented to attempt to prevent falls as evidenced by Resident #64 falling.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow the oxygen safety policy by not posting cautionary and safety signs indicating the oxygen in use 1 Resident (Resident #10) for the use of oxygen therapy of 1 sampled resident. The facility failed to complete a comprehensive care plan for 1 Resident (Resident #23) and failed to follow physician orders for 1 Resident (Resident #53).

Inspectors wroteBased on observation and interview, the facility failed to ensure that the medication cart for 100 Hall was locked and secured at the nurses station when the nurse was not in eyesight of the medication cart. This failed practice affected 10 sampled Residents (#3, #21, #23, #26, #34, #39, #53, #55, #64, and #170), and had the potential to affect 47 Residents in the facility that are capable of ambulating or self-propelling in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the nutritional value of the pureed food items to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 12 residents who receive a puree diet, as documented on a list 12/07/2023 at 04:40 PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure mechanical soft items were chopped or ground to minimize the risk of choking or other complications for residents who required a mechanical soft diet for 1 of 2 meals observed. This failed practice affected 1 Resident #55 of 1 sampled Resident who is on a mechanical soft diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional environment for residents, staff, and the public for 1 of 1 cook stoves. This failed practice had the potential to affect 69 residents as documented on the Daily Census provided by the Administrator on 12/05/2023 at 2:05 PM.

Inspectors wroteBased on observation, interview and record review facility failed to sit next to residents while assisting them to eat, rather than standing over them to promote care in a manner and environment that enhances each resident ' s dignity and respect. This failed practice affected 1 (Resident #25) and had the potential to affect 2 sampled (Residents #25, and #26) residing on 200 Hall requiring assistance with meals and snacks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by not closing the electronic medication administration record when not in use. This failed practice had the potential to affect 28 residents who receive medication from medication carts in the facility on hall 100 as documented on a list provided by the Administrator on 12/06/23 at 9:55 AM.

Inspectors wroteBased on observations, record review and interviews the facility failed to complete comprehensive care plan for 1 (Resident 10) of 1 sampled resident for the use of oxygen therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 1 of 24 residents receiving incontinence care in 100 hall (Resident #35) received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure peripherally inserted central catheter (PICC) care was provided and the dressing was changed in a timely manner affecting 1 (Resident #39) receiving PICC line care. This failed practice had the potential to cause skin breakdown and/or infection.