Care One at New Bedford

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure one Resident (#57), out of a total sample of 27 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #57, to implement treatments from the wound consultant physician for an unstageable pressure ulcer (wound covered with necrotic (dead) tissue making it difficult to determine stage) of the coccyx.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in three nourishment kitchenettes; and2. 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 from one surface to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease) and other opportunistic waterborne pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#137), out of a total sample of 27 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #137's right hand contracture (shortening/tightness to the muscle, tendons, ligaments, skin and other tissues resulting in difficulty moving the affected joint) was developed and implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#94) was administered medications in accordance with professional standards of quality, in a total sample of 27 residents. Specifically, the facility failed to ensure that nurses administering medications ensured Resident #94 had taken the medications.

Inspectors wroteBased on observation, document review, and interview, the facility failed to maintain complete and accurate medical records for two Residents (#2 and #10), out of a total sample of 27 residents. Specifically the facility failed to:1. Ensure Resident #2 had documentation in their medical record of their full diagnoses and psychiatric history, including a historical diagnosis of Schizoaffective disorder; and2. Ensure Resident #10's medical record contained only his/her health information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two Residents (#13 and #7), out of seven residents reviewed. Specifically, the facility failed: 1. For Resident #13, to accurately reflect if the Resident was utilizing a restraint on the most recent quarterly MDS and;2. For Resident #7, to accurately reflect if the Resident was being administered insulin on the two most recent quarterly MDSs.

Inspectors wroteBased on records reviewed, interviews and observations for one of three nursing units (Unit #1), with two (2) medication administration carts (A & B), the facility Failed to ensure it provided a separate locked, permanently affixed compartment for storage of medications that were controlled substances and/or other drugs subject to abuse, when both medication administration carts narcotic boxes were able to be opened without the use of a key, making these medications easily accessible.

Inspectors wroteBased on records reviewed, interviews, and observation, for one of seven (7) sampled residents (Resident #7) who should have been on Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of Multi-Drug-Resistant Organisms (MDRO) in nursing homes) related to wound care needs, the Facility failed to ensure nurses were aware of the need to use EBP's and implemented the necessary infection control practices during the provision of care.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure for three Residents (#11, #73, and #133), out of a total sample of 25 residents, that the Residents were free from significant medication errors. Specifically, the facility failed to ensure pain medicine was administered according to the pain scale indicated in the physician's orders.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#133), out of a total sample of 25 residents. Specifically, for Resident #133 the Pharmacist failed to review and report irregularities related to the administration of a medication.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for five Residents (#127, #11, #133, #13, and #141), out of 25 sampled residents. Specifically, the facility failed: 1. For Resident #127, to ensure a formal assessment instrument/tool was accurately coded on the MDS; 2. For Resident #11, to ensure an antianxiety medication was accurately coded on the MDS; 3. For Resident #133, to ensure a diuretic medication was accurately coded on the MDS; 4. For Resident #13, to ensure an antipsychotic medication was accurately coded on the MDS; and 5. For Resident #141, to ensure the accurate discharge location was accurately coded on the MDS.

Inspectors wroteBased on observation, document review, and interview, the facility failed to properly store and label food in the facility kitchen and on 3 out of 3 unit nourishment kitchens in accordance with professional standards of practice to ensure food safety. Specifically, the facility failed to: a. properly label beverage items in 1 of 2 freestanding refrigerators in the kitchen, and b. ensure food and beverages were properly stored and labeled in 3 out of 3 unit nourishment kitchens.

Inspectors wroteBased on interview, the facility failed to develop, implement, and maintain a comprehensive Compliance and Ethics program as required.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#11, #19, #68, #86, #112, #28, and #80), out of 28 sampled residents. Specifically, the facility failed to: 1. For Resident #11, develop a comprehensive care plan for: a. frequent urinary tract infections, Extended Spectrum Beta-Lactamase (ESBL: enzymes that break down and destroy some commonly used antibiotics, including penicillins and cephalosporins, and make these drugs ineffective for treating infections) and prophylactic use of Hiprex (medication used to prevent or control returning urinary tract infections caused by certain bacteria), and b. the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 2. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for nine Residents (#53, #62, #112, #86, #19, #68, #63, #232, and #80), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #53, to ensure diabetic management; 2. For Resident #62, to ensure orders were in place for monitoring hyper/hypoglycemia with treatment interventions to address the potential for hyper/hypoglycemia; 3. For Resident #112, to ensure orders were in place for: a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS (finger stick blood sugars) to obtain blood glucose levels in order to implement a sliding scale, and c. FSBS to obtain blood glucose levels in order to implement the hypoglycemic protocol; 4. [...]

Inspectors wroteBased on observation, policy review, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for two Residents (#85 and #62), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #85, to ensure that Oxygen (O2) was administered according to physician's orders, maintain consistent documentation of Oxygen liter flow, and ensure proper care and storage of respiratory equipment; and 2. For Resident #62, to ensure proper care and storage of respiratory equipment.

Inspectors wroteBased on document review, observation, and interview, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice set forth by the Centers for Disease Control and Prevention (CDC) and manufacturer's guidelines during a COVID-19 outbreak in the facility.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to ensure the call system button was accessible to the Resident in order to summon assistance when needed.

Inspectors wroteBased on record review, document review, and interview, the facility failed to notify the resident's representative (family member) of a room change for one Resident (#80), out of a total sample of 28 residents.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to assess and re-evaluate the use of a Velcro alarmed seatbelt as a restraint for one Resident (#19), out of a total sample of 28 residents.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to ensure nutritional status was maintained for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to follow their policy for weight monitoring.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) were provided in accordance with professional standards and physician's orders for one Resident (#100), out of 5 residents in the facility with feeding tubes, and a total sample of 28 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure that care and treatment of a Mid-line catheter (venous access device-VAD-which is located directly in the basilic vein of the arm and terminates at the axilla) was provided in accordance with the facility's policy/protocols for one Resident (#233), out of a total sample of 28 residents. Specifically, the facility failed to ensure staff assessed/documented the condition of, and the length of, the Mid-line catheter once it was discontinued/removed, according to the facility's policy/protocols.

Inspectors wroteBased on interview and record review, the facility failed to ensure that for one Resident (#82), out of a total sample of 28 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 observation, interview, document, and policy review, the facility failed to ensure all medications used in the facility were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in 1 out of 3 medication carts reviewed and properly disposed of an outdated medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff maintained medical records that were accurate for one Resident (#82), out of a total sample of 28 residents. Specifically, the Resident's medical record demonstrated discrepancies with their advanced directive.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure infection control practices were implemented during medication pass.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement the Antibiotic Stewardship protocols by not monitoring the continued/appropriate use of prophylactic antibiotics for two Residents (#80 and #11), in a total sample of 28 residents.