Care One at Lowell

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician visits were completed timely, completed as required for new admissions, and were alternated between the physician and the nurse practitioner for seven Residents (#26, #27, #144, #8, #129, #120 and #89) out of a total of 34 sampled residents. Specifically: 1. For Residents #26, #27 and #144, the facility failed to ensure they were seen by the physician as required after admission to the facility. 2. For Residents #8, #89, #120 and #129, the facility failed to ensure they were seen by the physician as required.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for one Resident (#11) out of 34 total sampled residents. Specifically, for Resident #11, the nurses inaccurately documented insulin was administered when it was not.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#133), out of 34 total sampled residents. Specifically, the facility failed to ensure Resident #133's sink was not leaking and good repair.

Inspectors wroteBased on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#115), when he/she was discharged from hospice services, out of a total sample of 34 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#140) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled residents. Specifically, the facility failed to ensure nursing changed the water flush bag (a bag containing water that is connected to and delivers water for hydration through a gastrostomy tube) every 24 hours as necessary to prevent infection and maintain the integrity of the feeding system.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#125) out of sample of 34 residents. Specifically, for Resident #125, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.

Inspectors wroteBased on observations, interviews, and record reviews for two Residents (#62 and #126) out of five residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, 1.) For Resident #62, the nurse administered the incorrect dose of atorvastatin calcium (a medicine used to treat high cholesterol). 2.) For Resident #126, the nurse failed to ensure an order for aspirin included a dosage prior to administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure diagnostic test results were maintained in the clinical record for one Resident (#120) out of a total of 34 sampled residents. Specifically, the facility failed to ensure the results of an ultrasound were reviewed and reported to the attending physician and filed in his/her clinical record.

Inspectors wroteBased on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations for three Residents (#129, #144 and #93) out of a total of 34 sampled residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to ensure they conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy.

Inspectors wroteBased on observation, record review and interview, the facility failed to monitor and assess the use of equipment being used as a potential restraint for one Resident (#57) out of a total sample of 31 residents. Specifically, the facility staff failed to: For Resident #57, conduct individualized monitoring and ongoing assessments for the use of thigh bands (used to secure the body in a wheelchair to prevent sliding down in the chair and designed to relieve pressure on certain body areas) while lying flat.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop a comprehensive plan of care for one Resident (#132) out of a total sample of 31 residents. Specifically, the facility failed to develop an individualized plan of care for Resident #132 related to migraine headaches.

Inspectors wroteBased on record review and interview, the facility failed to follow professional standards of practice for two Residents (#150 and #151) out of two closed records reviewed. Specifically, 1. For Resident #150, the facility failed to obtain a doctor's order for a transfer to the hospital and 2. For Resident #151, the facility failed to obtain a doctor's order for a transfer home.

Inspectors wroteBased on record review and interview the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop an individualized comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#146 and #123) who had an active diagnosis of PTSD out of a total sample of 31 Residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide dental services for one Resident (#132) out of a total sample of 31 residents. Specifically: For Resident #132, the facility failed to ensure dental services were provided after it was reported that Resident #132 had dental pain.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure that housekeeping staff maintained proper hand hygiene practices on one of four nursing units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#71) out of a total sample of 31 residents. Specifically, the facility coded Resident #71 as using a trunk restraint when he/she did not use one.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#63) out of a total sample of 37 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure Medical Orders for Life Sustaining Treatment (MOLST) were accurate for 1 Resident (#3), out of a total 37 sampled residents. For Resident #3, the facility failed to address the advance directives on the MOLST in the plan of care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to meet professional standards of practice during a medication pass with 1 Resident (# 34) out of 3 residents observed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADL) for 1 Resident (#148) out of a total sample of 37 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to follow recommendations of the optometrist for 2 Residents (#63 and #120) out of a total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff provided appropriate care and services for one Resident (#3) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 37 sampled Residents. Specifically, the facility failed to follow physician orders for accurate water flush amount. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. [...]

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure that 1 Resident (#63), was seen by a physician every 90 days out of a total sample of 37 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One nurse out of two nurses observed made 3 errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#111 and #22) out of 3 residents observed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide dental services to 1 Resident (#120) out of a total sample of 37 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff maintained medical records that were accurate for one Resident (#3) out of a total sample of 37 residents. Specifically, the facility documented that the incorrect enteral flush order was administered. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. During observations on 4/5/23 at 11:48 A.M., 4/5/23 at 11:48 A.M., 3:11 P.M. [...]