Cape Heritage Rehabilitation & Health Care Center

Inspectors wroteBased on records reviewed, interviews and observations, for one of three sampled residents (Resident #1) who during his/her admission assessments informed staff that his/her dietary preference was skim milk, the Facility failed to ensure that he/she received his/her drink of preference as identified on his/her care plan and nutritional assessment.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of and properly contained within a receptable constructed with a tight-fitting lid.

Inspectors wroteBased on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in a safe operating condition, specifically (1) the walk-in freezer, (2) the stove hood, and (3) the ice machine.

Inspectors wroteBased on observation and interviews, the facility failed to maintain their septic system drain field in working order and/or increase pumping of their septic tank to prevent the liquid wastewater from running into their parking lot.

Inspectors wroteBased on interviews and observations, the facility failed to ensure it provided a clean, comfortable, and homelike environment for the residents residing on one unit ([NAME]) out of three units.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Resident with an alteration in skin integrity related to a wound, specifically a gastrocutaneous fistula (an abnormal opening between the stomach and the skin allowing gastric contents to leak onto the skin) at an old feeding tube site, received necessary treatment and services to promote healing for one Resident (#85), out of a total sample of 23 residents. Specifically, the facility failed to transcribe and implement wound care per recommendations by the stoma clinic, complete wound care as ordered, and to notify the physician when the surrounding skin at the wound site was macerated (white and soggy skin from exposure to excessive moisture from body fluids).

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain one of three kitchenettes in a clean and sanitary condition; and 2. Properly label and date food products in the main kitchen walk-in refrigerator.

Inspectors wroteBased on observation, interviews, and test tray results, 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 two 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 food items were properly labeled and dated in the main kitchen refrigerators; 3. Ensure food and drink items were properly stored, labeled, and dated in two of three kitchenettes; 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 (biological contaminants) from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility failed to repair areas of chipped and loose textured ceiling, also known as popcorn ceiling, in five resident rooms in one out of three units.

Inspectors wroteBased on interviews, record review, and policy review, for one Resident (#66) of 21 sampled residents, the facility failed to ensure all alleged violations of abuse, neglect, exploitation, or mistreatment were reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS-a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) as required. Specifically, for Resident #66, the facility failed to report alleged abuse by a visitor within the required timeframe.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, for residents on the [NAME] unit (a locked dementia unit), the facility failed to ensure psychotropic medication was secured and not accessible to residents.

Inspectors wroteBased on records reviewed, policy review, and interviews, for one Resident (#66), out of 21 sampled residents, the facility failed to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, for Resident #66, the facility failed to ensure his/her weight was documented in the medical record as ordered by the physician.

Inspectors wroteBased on observations, interviews, 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 potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly dispose of cigarette butts in designated smoking receptacles.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to maintain an infection control and prevention program to help prevent the potential transmission of a communicable disease when the facility was experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to implement outbreak testing for both staff and residents in accordance with the most current guidance and the facility policy.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure adequate supervision and develop and implement fall interventions for one Resident (#4), out of a sample of 19 residents, resulting in a fall with major injury.

Inspectors wroteBased on interviews and record review, the facility failed to monitor the nutritional status of two Residents (#43 and #42), out of a total sample of 19 residents. Specifically, the facility 1. Failed to monitor the weight loss of Resident #43, resulting in a significant weight loss; and 2. Failed to implement nutritional interventions for Resident #42.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the needs of two Residents (#43 and #40), in a total sample of 19 residents. Specifically, the facility failed 1. For Resident #43, to ensure weekly weights were obtained to monitor weight loss, resulting in significant weight loss; and 2. For Resident #40, to ensure wound care was provided as ordered.

Inspectors wroteBased on interview, review of employee education files, and document review, the facility failed to ensure nursing staff received the appropriate competencies and skill sets for 5 out of 5 licensed nurses.

Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively in the kitchen.

Inspectors wroteBased on interviews and observations, facility failed to ensure that food was palatable and served at an appetizing temperature.

Inspectors wroteBased on policy review and interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that described their approach to improving the quality of life, care, and services delivered to residents in the facility.

Inspectors wroteBased on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure infection control policies and procedures were reviewed at least annually; 2. Document staff with signs/symptoms (e.g., fever) of COVID-19 according to their surveillance plan; 3. Implement return to work criteria for healthcare personnel (HCP) with SARS-CoV-2 infection; 4. Implement appropriate use of personal protective equipment (PPE); 5. Post proper signage for residents on transmission-based precautions (TBP) to ensure staff were aware of precaution needs; 6. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to develop an antibiotic stewardship program that promoted appropriate use of antibiotics and included a system to monitor antibiotic use. Specifically, the facility failed: 1. To adequately track infections to review for trends and review antibiotic therapy usage to provide feedback, and 2. For Resident #40, to ensure the criteria for the initiation of antibiotics, per the facility's policy and infection control requirements, was followed.

Inspectors wroteBased on interview, policy review, and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00 P.M. the following day.

Inspectors wroteBased on observation, interview, policy review, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests. Specifically, the facility failed to: 1. Ensure testing of staff whose COVID-19 vaccination status was not up to date was based on the level of community transmission according to the recommended frequency; 2. Ensure documentation of COVID-19 testing was completed including the results of each staff test, and 3. Perform BinaxNOW COVID-19 Ag Card testing (rapid testing) correctly for five out of five staff members observed.

Inspectors wroteBased on interviews and record review, the facility failed to consult with the resident's physician for four Residents (#3, #43, #40, #147 and #6), out of 19 sampled residents. Specifically, the facility failed to notify physicians of the following: 1. A recommended antipsychotic medication for Resident #3 with delusions and hallucinations; 2. A change in weight for Resident #43 with a history of significant weight loss; 3. A recommendation to a change in wound treatments for Resident #40; 3. A new prescription from an Endocrinologist for Resident #147; and 4. A recommended antipsychotic medication, Seroquel, for Resident #6.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#8, #38, #48, #6, #94, #77, and #147), out of 19 sampled residents. Specifically, the facility failed: 1. For Resident #8, to develop a care plan for the use of a blood thinning medication; 2. For Resident #38, to implement care plan interventions for falls; 3. For Resident #48, to implement care plan interventions for an indwelling urinary catheter; 4. For Resident #6, to develop a comprehensive care plan for psychotropic medication use that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 5. For Resident #94, to develop a care plan for smoking; 6. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure Residents were provided care in accordance with professional standards of practice for four Residents (#4, #90, #6, and #8), from a total sample of 19 residents. Specifically, the facility failed 1. For Resident #4, to ensure physician's orders for a bowel protocol was implemented which resulted in the Resident not having a bowel movement for seven days; 2. For Resident #90, to ensure the physician's order for an air mattress was implemented and accurately documented; 3. For Resident #6, to ensure a physician's order was transcribed as per the acceptable professional standards of clinical practice; and 4. For Resident #8, to ensure the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into a larger vein to administer intravenous (IV) treatments over a long period of time). Specifically, the facility failed to ensure staff (a) administered flushes, (b) changed the dressing, (c) measured the external catheter length, and (d) monitored the IV site for one Resident (#77), out of a total sample of 19 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that emergency drug kits were re-ordered when medications were dispensed from the emergency kits in two out of three medication rooms observed.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to ensure that for six Residents (#38, #48, #4, #90, #40, and #19), out of a total sample of 19 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure all medications used in the facility were safely stored in accordance with currently accepted professional principles. Specifically, the facility failed to maintain a temperature log for one out of one medication refrigerators to preserve the integrity of the vaccines stored.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure all residents were offered the COVID-19 vaccine unless immunization was medically contraindicated, or the resident had already been immunized for 38 of 92 residents currently residing in house.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to 1) Develop a COVID-19 vaccination policy for staff that included all the required components that were current and based on national standards; 2) Ensure additional precautions, intended to mitigate the transmission and spread of COVID-19, were implemented for all staff who were not fully vaccinated for COVID-19; and 3) Track and document the COVID-19 vaccination status for two of eight staff members sampled.

Inspectors wroteBased on observation and interview, the facility failed to maintain a functioning call light system on 1 of 3 Resident units.

Inspectors wroteBased on observations and interviews, the facility failed to: 1. Promote dignity while dining for all residents in the facility by serving meals in Styrofoam containers for almost a year; and 2. Ensure the dignity of Resident (#48) by not covering a urinary catheter bag.

Inspectors wroteBased on interview and record review, the facility failed to ensure advanced directive decisions were made by the activated Health Care Proxy (HCP) for Resident #37, who was deemed to lack capacity to make health care decisions. The total sample was 19 residents.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#6), from a total sample of 19 residents. Specifically, facility failed to ensure Resident #6 was provided privacy during a neuropsychiatric evaluation conducted by the facility's consultant Psychiatrist in the Resident's room.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#4 and #72), out of a total sample of 19 residents. Specifically, the facility failed to ensure 1. For Resident #4, two incidents of bruises of unknown origin were thoroughly investigated and reported to the Department of Public Health (DPH) as required; and 2. For Resident #72, an allegation of sexual abuse was thoroughly investigated.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) for one Resident (#4), out of a total sample of 19 residents.

Inspectors wroteBased on policy review, interviews, and record review, the facility failed to ensure allegations of abuse were investigated for two Residents (#4 and #72), out of a sample of 19 residents. Specifically, the facility failed: 1. For Resident #4, to investigate two incidents of bruises of unknown origin; and 2. For Resident #72, to investigate allegations of sexual abuse and report results to the representative.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Resident and/or the Resident's representative and the Ombudsman were provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for one Resident (#95), out of a total sample of 19 residents and three closed records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an accurate comprehensive Minimum Data Set (MDS) assessment was completed for one Resident (#94), in a total sample of 19 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for one Resident (#40), out of a total sample of 19 residents. Specifically, the facility failed for Resident #40, to review and revise the care plan to indicate a new pressure injury developed from the use of a catheter leg bag and to indicate interventions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#43) received assistance with eating. The total sample was 14 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure wound care was provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatments to a pressure injury were provided in accordance with professional standards of practice to promote healing for one Resident (#40), in a total sample of 19 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Resident #72, admitted with a catheter was assessed for the removal of the catheter as soon as possible, out of three sampled residents with catheters.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide the appropriate treatment and services to administer medications and prevent complications of an enteral feeding tube (a method of providing nutrition and fluids directly into the stomach via a gastric tube (G-tube), which is inserted through the abdominal wall to give direct access to the stomach or upper intestines) to one Resident (#67), out of a total sample of 19 residents.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility 1. Failed to provide care and treatment in accordance with the facility policy/protocols and professional standards of practice for one Resident (#77) with a trachea/laryngeal stoma (a stoma is a surgically created hole (opening) made in the windpipe/skin in front of your neck to allow you to breathe). Specifically, the facility failed to: a.) Obtain physician's orders to provide a person-centered care plan for care of trachea/laryngeal stoma; b.) Implement the facility protocol to maintain a clear and patent airway; and c.) Provide emergency bedside tracheostomy equipment needed for accidental occlusion (the blockage or closing of an opening) or mucus plugging (buildup of thick mucus); and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that for three Residents (#8, #90, and #67), out of a total sample of 19 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of an anticoagulant (blood thinner) medication.

Inspectors wroteBased on observations and interviews, the facility failed to provide food that accommodated the preferences of 1 Resident (#94), in a total sample of 19 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain medical records that were complete, accurate, and systemically organized within accepted professional standards of practice for two Residents (#77 and # 67), out of a total sample of 14 residents. Specifically, the facility failed to ensure: 1. For Resident #77, the documentation on the Medication Administration Record (MAR) was accurate and completed on the date specified; and 2. For Resident #67, the Decree and Order of Appointment of Guardian for an Incapacitated Person was included as part of the medical record, readily accessible, and confirmed the guardian's authority to sign the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form.

Inspectors wroteBased on record review and interviews, the facility failed to define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility, including infection control practices, Quality of care, falls, and medication review.