Cambridge Post Acute Care Center

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments were completed to ensure communication with the dialysis facility for one of two residents (Resident (R) 10) reviewed for dialysis of 32 sample residents. This failure had the potential to lead to uncommunicated and unassessed changes or complications for R10 and other residents receiving dialysis.

Inspectors wroteBased on observations, record review, staff interviews, and facility policy review, the facility failed to follow infection control guidelines during wound treatment for one of two residents (Resident (R) 10) reviewed for pressure ulcers and failed to follow infection prevention measures when an indwelling urinary catheter bag was placed on the floor for one of two residents (R10) reviewed for catheters of 32 sample residents. These failures had the potential to cause infections in the wound and the urinary tract for R10.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Resident Rights, the facility failed treat one of 9 sampled residents (R) (R9) in a dignified manner.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Care of Central Venous Catheters including provide Peripherally Inserted Central Catheters (PICC Lines), the facility failed to provide appropriate treatment and services to one of 10 sampled residents (R) (RB). Specifically, PICC line dressing protocol was not followed, a chest x-ray was not ordered or performed and the PICC line was used without confirmation of placement, and dressing changes were not done according to facility policy and physician's orders.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policy titled, Medication Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from significant medication error.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Infection Control and Dressings, Non-Sterile, the facility failed to follow infection control practices related to Enhanced Barrier Precautions and consistent hand hygiene when providing wound care for two of 16 residents (R) (R4 and R15) receiving wound treatment. The deficient practice had the potential of transmission of communicable diseases and infections.

Inspectors wroteBased on observation, staff interview, and review of the facility's policy titled Giving a Bed bath, the facility failed to ensure residents' basins, urinals, and bedpans were labeled and covered for 11 of 69 shared rooms (D2, D5, D18, D16, C9, C15, B16, B5, A15, A5, and A11). These failures had the potential to expose patients to infections due to cross-contamination.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medication Program, the facility failed to ensure that three of 56 residents (R) (R45, R113, and R432) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Care Plan-Comprehensive, the facility failed to develop a comprehensive person-centered care plan for two out of 56 residents (R) (R35 and R6). Specifically, the facility failed to develop a comprehensive person-centered care plan for R35 related to Methicillin-resistant Staphylococcus aures (MRSA) and R6 related to oxygen therapy.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Oxygen Safety, the facility failed to ensure one resident (R) (R6) was administered oxygen therapy in accordance with the physician order and to ensure that the oxygen concentrators' filters remained clean for three residents (R98, R64, and R105) out of 19 residents receiving respiratory treatments. This deficient practice had the potential to put residents at risk for increased respiratory infections, medical complications and potentially life-threatening complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Administering Medications, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 26 opportunities for one of five residents R (R35) for a medication error rate of 7.69 percent. These failures had the potential to place R35 at risk of medical complications and decreased therapeutic effects of medications.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled Bed Hold Policy, the facility failed to provide written information about the facility's bed-hold policy to the resident or resident representative when the facility transfers a resident to the hospital for three of three residents (R) (R3, R14, R17) reviewed for Bed Hold. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital.

Inspectors wroteBased on record review, interviews, and review of the policy titled Antibiotic Stewardship, the facility failed to assess and determine clinical indications for use of antibiotics utilizing the McGreer Criteria, failed to implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for two of three sampled residents (R) (R16 and R17).

Inspectors wroteBased on record review, interviews, and review of the policy titled Infection Control -Infection Preventionist, the facility failed to ensure that the person in the role of the Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. The facility census was 136.

Inspectors wroteBased on observations, interviews, and review of the policy titled Maintenance Service, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Specifically, the facility failed to address and remove bulking wallpaper and water-stained ceiling tiles from room C14. In addition, the facility failed to maintain the aesthetic appeal of the exterior of the facility and a clean and safe porch area at the entrance of the facility. The census was 136.

Inspectors wroteBased on record review, interview, and review of the policy titled Care Plan-Goals and Objectives, the facility failed to develop a comprehensive person-centered plan of care which included a focus, goal, and interventions related to communication for four of four residents (R) (R4, R18, R26, and R27) reviewed for communication needs. Specifically, the facility failed to develop a care plan related to hearing loss for R4 and failed to develop a care plan for R18, R26, and R17 related to language barrier for non-English speaking residents.

Inspectors wroteBased on observations, interviews, and a review of the policy titled Certification Medication Aide Program, the facility failed to ensure that services provided by Certified Medication Technicians (CMTs) met professional standards of quality. Specifically, the facility failed to provide evidence that three of five CMTs (CMT MM, CMT LL, and CMT FF) were competent with skills and knowledge to provide insulin administration, before being allowed to administer insulin to residents. This failure had the potential to result in adverse outcomes for residents related to medication administration.

Inspectors wroteBased on record review, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure medications were administered as ordered for two of three residents (R) (R17 and R25) reviewed for medication administration. Specifically, R17 missed 20 doses of her inhaler (Xopenex) and Atorvastatin 13 times, as ordered; and R25 missed seven doses of Pregabalin (Lyrica-can be used for nerve pain). The deficient practice had the potential for adverse consequences and events due to not receiving ordered and scheduled medications timely.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Diabetes Care-Insulin Administration and Administration of Drugs, the facility failed to ensure staff administered insulin as ordered for three of five residents (R) (R15, R11, R5) reviewed for insulin administration. Specifically, there were multiple discrepancies in the blood sugar (BS) documentation and insulin sliding scale orders, as well as multiple days and times with no documentation that insulin was administered. This failure placed the residents at risk of hypoglycemia, hyperglycemia, and a diminished quality of life.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) and transmission-based precautions (TBP) were implemented for two residents (R) (R19 and R20) of four residents reviewed for infection control. Specifically, the facility failed to have personal protective equipment (PPE) supplies readily available and accessible for use by staff when providing high-contact care. This failure had the potential to expose residents to infections due to cross-contamination.

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plan-Goals and Objectives, the facility failed to ensure the person-centered comprehensive care plan was revised related to interventions for a sacral pressure ulcer for one resident (R)(R19) of three residents reviewed for pressure ulcers. This failure placed the resident at risk for unmet care needs.

Inspectors wroteBased on observations, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure expired insulin vials were removed from two of five medication carts. This failure placed the residents at risk of being administered ineffective medications. The census was 136.

Inspectors wroteBased on record review, interviews, and review of the policy titled Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, the facility failed to provide education, offer, or provide the pneumonia vaccination for one of five sampled residents (R) (R18) reviewed for pneumonia vaccinations. This deficient practice had the potential to increase the spread of pneumonia among unvaccinated residents.

Inspectors wroteBased on record review, interviews, and review of policy titled Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, the facility failed to ensure one of five sampled residents (R) (R19) reviewed for Covid-19 immunizations, was provided education regarding the benefits, risks, potential side effects associated with the vaccine, was offered the Covid-19 vaccine, or declined the vaccine. This failure had the potential to place the resident at risk of acquiring and/or transmitting Covid-19.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for weight loss for one resident (R) of 39 residents, R#54. Specifically, the facility failed to accurately code Section K of the MDS assessment for R#54 which reflected that the resident was on a prescribed weight loss program. Findings Include: Record review revealed R#54 was admitted to the facility on [DATE] with diagnoses that included but not limited to fluid overload, morbid (severe) obesity, dependence on renal dialysis, end stage renal disease (ESRD), anemia in chronic kidney disease and heart failure. Review of Registered Dietician (RD) Nutritional assessment dated [DATE], revealed R#54 was on a Renal, Regular texture, thins; [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that one resident (R) of 39 residents, (R#30), was assessed for level two Preadmission Screening/Resident Review (PASRR). This deficient practice had the potential to affect the appropriate level of care and services provided for R#30.

Inspectors wroteBased on record review, observations, staff interview, and review of the facility policy titled Medication and Treatment Orders the facility failed to ensure that licensed nursing staff accurately documented the medication administration record for one resident (R) of three residents (R#25) reviewed for intravenous (IV) fluids/medications. Specifically, the facility failed to document that R#25 received the IV fluids as per the active physician's order (PO).