Care One at Millbury

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted to the facility, and whose Physician orders included administration of Teriparatide (parathyroid hormone used to treat osteoporosis) injectable pen, which required refrigeration, the facility failed to ensure nursing stored the medication in accordance with manufacturer recommendations when the medication was not refrigerated as required.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an invoked Health care Proxy (HCP) and whose Advanced Directives while in the hospital prior to his/her transfer to the facility, had been DNR (Do not Resuscitate)/DNI (Do not Intubate), the Facility failed to ensure that Resident #1 and/or his/her Health Care Agent choices related to the formulation of advanced directives were appropriately addressed by staff upon admission.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate supervision and assistive devices to ensure one of three sampled residents (Resident #1) remained free from accident hazards during transfers, resulting in Actual Harm. Specifically, for Resident #1, who was assessed as being at high risk for falls and requiring a two-person stand aid for safe transfer, two Certified Nurse Aides (CNAs) attempted a manual transfer after the resident reportedly refused the stand aid, gait belt, and Hoyer lift. The CNAs failed to wait for supervision (Nurse or Rehabilitation staff) to intervene regarding the refusal, which resulted in an unsafe transfer contrary to the resident's care plan, demonstrating a failure to implement safety protocols when an assistive device required by the care plan was refused. [...]

Inspectors wroteBased on observations, interviews, and record reviews for two Residents (#94 and #38) out of a total sample of 29 residents, the facility failed to notify the Physician/Nurse Practitioner (NP) of the need to significantly alter treatment (need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Specifically, 1. For Resident #94, the facility failed to notify the Physician/NP of the Resident's uncontrolled pain during indwelling urinary catheter care and 34 missed doses of Lidocaine (pain medication) Gel, out of 46 ordered doses, to be applied topically for the Resident's genital pain resulting in ineffective pain management. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice and the Resident's comprehensive person-centered care plan was provided for one Resident (#94) out of a total sample of 29 residents. Specifically, for Resident #94, the facility failed to: -adequately assess the Resident's pain during personal care of an indwelling urinary catheter when facility staff were aware the Resident had a genital wound and experienced pain during urinary catheter care, resulting in the Resident experiencing pain during indwelling urinary catheter related procedures. -provide interventions for pain management during personal care of an indwelling urinary catheter which resulted in the Resident anticipating and experiencing pain relative to indwelling urinary catheter care. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to provide pharmacy services for routine medications for three Residents (#341, #94, and #38) out of a total sample of 29 residents. Specifically, 1. For Resident #341, the facility failed to procure and administer Amlodipine Besylate-Valsartan (high blood pressure medication) as ordered by the Physician when the Resident had a known history of Hypertension (high blood pressure). 2. For Resident #94, the facility failed to provide pharmaceutical services for obtaining Lidocaine Gel and Biofreeze (topical pain medications) when Lidocaine Gel and Biofreeze were ordered by the Physician to be administered to the Resident for pain management. 3. [...]

Inspectors wroteBased on interviews and records reviewed, the facility failed to maintain an effective, comprehensive, data-driven QAPI (Quality Assurance and Performance Improvement - a comprehensive approach in healthcare that combines quality assurance and performance to systematically monitor and evaluate the quality and appropriateness of systems and process with a goal to enhance patient care and improve outcomes through a data-drive, proactive approach) program relative to pharmaceutical services for three Residents (#341, #94, and #38) out of a total sample of 29 total residents, which resulted in ordered medications not being administered to the Residents. Specifically, the facility failed to develop and implement a performance improvement plan relative to pharmaceutical services when: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#40) out of a total sample of 29 residents, had the ability to make choices about their daily preferences. Specifically, for Resident #40, the facility failed to ensure the Resident's preference to be out of bed and dressed before breakfast was honored.

Inspectors wroteBased on record review, and interview the facility failed to accurately complete a Comprehensive Minimum Data Set (MSS) Assessment reflective of the status of two Residents (#128 and #340) out of a total sample of 29 residents. Specifically, 1. For Resident #128, the facility failed to conduct a Brief Interview for Mental Status (BIMS) Assessment in the Residents' primary language placing the Resident at risk for an inaccurate assessment, as well as inappropriate delivery of care and services. 2. For Resident #340, the facility failed to accurately code one comprehensive Minimum Data Set (MDS) Assessment to indicate the Resident had a surgical wound, when the Resident was admitted to the facility with a surgical wound, resulting in an inaccurate assessment of the Resident.

Inspectors wroteBased on observations, and interviews, the facility failed to provide adequate assistance for Activities of Daily Living (ADL - basic care task that an individual does on a day-to-day basis such as eating, bathing, dressing, grooming and mobility) for one Resident (#126) out of a total sample of 29 residents. Specifically, for Resident #126, the facility failed to ensure that the Resident who desired to have his/her facial hair removed and required assistance, was offered facial grooming care, resulting in unwanted facial hair.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice relative to post-operative care of a non-pressure skin condition for one Resident (#340) out of a total sample of 29 residents. Specifically, the facility failed to assess Resident #340's surgical wound and implement post-operative instructions for surgical wound care, when the Resident was admitted to the facility with a surgical incision site on his/her neck, putting the Resident at risk for infection and delayed wound healing.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide care and services, consistent with professional standards of practice and the Resident's comprehensive person-centered plan of care relative to the care of an indwelling urinary catheter for one Resident (#94) out of a total sample 29 residents. Specifically, the facility failed to adhere to a Physician order for elevating Resident #94's genital area when the Resident experienced an indwelling catheter associated complication of genital slit and swelling, increasing the Resident's risk for further urinary catheter associated complications.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide care and maintenance of intravenous (IV) therapy consistent with professional standards of practice for two Residents (#343 and #68), out of a total sample of 29 residents. Specifically, 1. For Resident #343, the facility failed to ensure nursing staff correctly transcribed and administered Physician orders for a Peripherally Inserted Central Catheter (PICC) relative to flushing when the Resident was admitted to the facility with a PICC line in place, placing the Resident at risk for PICC line blockage and impaired medication administration. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food that was palatable, and at an appetizing temperature on one Unit ([NAME] Unit) out of three units observed. Specifically, the facility failed to ensure that meals maintained a palatable temperature when served to the residents and that meal trays were provided timely on the [NAME] Unit especially for residents requiring meal assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure choices were honored when the Resident had specific needs for one Resident (#38) out of a total sample of 29 residents. Specifically, for Resident #38, the facility failed to honor the Resident's preferences identified on the meal tray card and care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for three Residents (#100, #101, #343) out of a total sample of 29 residents. Specifically, 1. For Resident #100, the facility failed to ensure that staff wore the indicated Personal Protective Equipment (PPE: items such as gown and gloves worn by the staff member to decrease the chance of spread of infection) while in the Resident's room when he/she was on Contact Precautions (interventions including use of PPE to prevent the spread of a communicable disease). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Pneumococcal Vaccine was administered after consent was obtained to administer the vaccination for one Resident (#50), out of five residents sampled for immunizations. Specifically, for Resident #50, the facility failed to administer a Pneumococcal Vaccine after the Resident's activated Health Care Proxy (HCP) consented to the Resident receiving a Pneumococcal Conjugate Vaccine (PCV).

Inspectors wroteBased on interview, and record review, the facility failed to provide pertinent information pertaining to COVID-19 vaccinations for one Resident (#50), out of five residents sampled for immunizations. Specifically, for Resident #50, the facility failed to: 1. indicate whether the Resident and/or Resident's Representative were provided education regarding the benefits and potential risks associated with COVID-19 Vaccine. 2. whether the Resident and/or Resident's Representative consented to or declined the COVID-19 Vaccine.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included atrial fibrillation (irregular heartbeat) with a Physician's order for an anticoagulant (blood thinner) medication to manage the condition, the Facility failed to ensure he/she was free from significant medication errors, when due to a transcription error by nursing, Resident #1 was administered two different anticoagulant medications for five days and on 1/24/24 he/she was found to have blood in his/her stool, blood laboratory work indicated he/she had a critical low hemoglobin (helps red blood cells carry oxygen to muscles and tissues) level, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and required admission for further treatment. Findings Include: Review of the Facility Policy titled, Physician Orders: [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to accurately identify a serious mental illness (SMI) on a Level I Preadmission Screening and Resident Review (PASARR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1. all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability, 2. be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3. receive the services they need in those settings) for one Resident (#346) out of a total sample of 28 residents. Specifically, the facility staff failed to identify that the Resident had diagnoses which met the SMI criteria.

Inspectors wroteBased on record and policy review, and interview, the facility failed to develop a Baseline Care Plan as required, for one Resident (#126) out of a total sample of 28 residents. Specifically, the facility staff failed to develop the Baseline Care Plan within 48 hours of admission to the facility for Resident #126, as a result impeding continuity of care and communication related to the Resident's needs, care and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Physician Orders and Plan of Care relative to pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) care and services was implemented for one Resident (#28), of four applicable residents who had pressure ulcers, out of a total sample of 28 residents.

Inspectors wroteBased on interview, policy, and record review, the facility failed to ensure that care plans were reviewed with the interdisciplinary team (IDT) as required and offer a resident the opportunity to participate in the care plan revision process for one Resident (#59), out of a total sample of 28 residents. Specifically, the facility staff failed to: -review the Resident's care plans with the IDT following the comprehensive Minimum Data Set (MDS) Assessment. -offer the Resident and/or Representative the opportunity to participate in the care plan review process when the Resident had concerns related to his/her care. Findings Include: Review of the facility policy titled Care Plans Comprehensive Person-Centered, last revised 4/25/22, indicated: [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that activities of daily living (ADLS- activities related to personal care which include bathing, dressing, grooming and eating) were provided timely for two Residents (#28 and #126), out of a total sample of 28 residents who were dependent on staff for care. Specifically, the facility failed to ensure that: 1. Meal assistance was provided timely for Resident #28, and 2. Personal care relative to grooming needs was provided timely for Resident #126

Inspectors wroteBased on interview, record and policy review, the facility failed to provide services to ensure that proper treatment and assistive devices to maintain vision and hearing were provided for one Resident (#50) out of a total sample of 28 residents. Specifically, the facility staff failed to ensure access to audiology services as ordered by a Physician and to facilitate a follow-up appointment as recommended by an Optometrist for Resident #50.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medications that affect the mind, emotions and behaviors) was assessed by the Provider every 14 days for one Resident (#55), out of a total sample of 28 residents. Specifically, the facility failed to assess the PRN order for Klonopin (an anti-seizure medication used to treat mood and behaviors) timely for Resident #55.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records as ordered by the Physician for one Resident (#94) out of a total sample of 28 residents, who had a feeding tube (a tube inserted surgically through the abdomen and into the stomach used to provide nutrition) and also consumed meals by mouth (PO). Specifically, the facility failed to ensure that fluid intake was recorded accurately for Resident #94: -where staff were documenting the administration of tube feeds on the day shift (7:00 A.M. - 3:00 P.M.) when the tube feeds were ordered by the Physician to be shut off at 6:00 A.M. -and evening snacks were documented as being provided when the Resident was not eating PO after the tube feeds were started.

Inspectors wroteBased on interview and record review the facility failed to ensure transportation was arranged for hemodialysis (HD) treatments for one Resident (#174) resulting in two missed dialysis treatments and a subsequent hospitalization, in a total sample of 25 residents.

Inspectors wrote2. For Resident #79 the facility staff failed to implement proper hand hygiene during dressing changes. Resident #79 was admitted to the facility in September 2020. Review of the August 2022 physician's orders indicated the following: -For skin tears to bilateral shins, cleanse with normal saline (NS), pat dry, cover with Xeroform a sterile, (non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum blend) then apply clean dressing daily until healed. -For shearing wound of the right lateral thigh, cleanse with NS, pat dry, cover with Xeroform and foam dressing daily. On 8/11/22 at 11:15 A.M., the surveyor observed Nurse #1 provide the wound care listed above. -Nurse #1 washed his hands, applied gloves, then removed the old dressing to the right lateral thigh. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that its staff performed weekly surveillance testing as required for two out of three sampled staff members. Review of the Massachusetts Department of Public Health (DPH) guidance titled Updates to Long-Term Care Surveillance Testing, dated 6/10/22, indicated the following: All LTC (Long-Term Care) facility staff who are up to date (UTD) with COVID-19 vaccines must conduct weekly testing. Staff who are not UTD with COVID-19 vaccines should be tested on two non- consecutive days during the testing week. Review of the staff vaccination matrix provided by the facility indicated that Staff #1 and Staff #2 were both UTD with COVID-19 vaccinations. Review of the time card punches for Staff #1 and Staff #2 indicated that both staff worked in the facility every week for the month of July 2022 and from 8/1/22 to 8/6/22. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff offered the opportunity to formulate an advance directive relative to life sustaining treatment for one Resident (#24) out of 25 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff issued a transfer notice to two Residents (#87 and #2), out of 25 sampled residents, that included the reason for a transfer to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff issued a bed-hold notice for two Residents (#87and #2) out of 25 sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that its staff followed the plan of care for two Residents (#79 and #74), out of 25 sampled residents. Specifically: 1) Implementation related to wound care for one Resident (#79), and 2) Application of a sling during transfers for one Resident (#74).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that its staff provided care of respiratory equipment for one Resident (#74) out of 25 sampled residents. Specifically: the facility staff failed to provide care and maintenance of a Continuous Positive Airway Pressure (CPAP - used to keep airways open for people who have sleep apnea) machine. Failure to clean and replace accessory equipment for this machine as ordered could contribute to upper airway infections resulting from dirty and contaminated equipment.

Inspectors wroteBased on interview and record review the facility and its staff failed to ensure a medication irregularity. Specifically, the need to rinse the mouth after the use of a corticosteroid inhaler to prevent oral yeast infection, identified by the Pharmacist was addressed by the Physician for one resident (#56) in a total sample of five residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff adhered to food safety requirements to prevent foodborne illness. Specifically, the facility failed to ensure two staff members with beards, working in the kitchen, wore hair restraints to contain their beards during meal service.