Care One at Northampton

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and reflective of the resident's status at the time of the assessment, for five Residents (#51, #11, #10, #3 and #4), out of a total sample of 21 residents. Specifically, the facility failed to:For Resident #51, accurately code that insulin injections were administered in the MDS assessment dated [DATE]. For Resident #11, accurately code that insulin injections and hypoglycemic (used to treat high blood sugar) medication were administered on the MDS assessment dated [DATE], and accurately code hospice services on the MDS assessment dated [DATE]. For Resident #10, accurately code that the Resident utilized tobacco and had sustained two falls during the reference period for the MDS assessment dated [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#8) of three applicable residents reviewed for incontinence, out of a total sample of 21 residents, was fully assessed and interventions implemented to assist in improving the Resident's episodes of incontinence. Specifically for Resident #8, the facility failed to: -accurately assess for bladder incontinence, and -complete a bladder retraining program

Inspectors wroteBased on interviews, and record reviews, the facility failed to implement a system of infection control surveillance relative to COVID-19 testing for four Residents (#23, #96, #31, #41) out of a total sample of 21 residents and on two (Federal and Elm) Units out of three Units. Specifically, the facility failed to test four Residents #23, #96, #31, #41 on the Federal Unit and Elm Unit, who were experiencing respiratory symptoms to rule out COVID-19 infection, placing other residents and staff at potential risk for infection.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that an antibiotic stewardship program was implemented for one Resident (#51), of two applicable residents reviewed for antibiotics, out of a total sample of 21 residents. Specifically, for Resident #51, the facility failed to obtain culture and sensitivity results timely to evaluate the appropriateness of the prescribed and administered antibiotic to treat a urinary tract infection (UTI) to ensure it would be effective in treating the specific bacteria identified from laboratory results.

Inspectors wroteBased on interviews and records reviewed for one of three sampled residents (Resident #1) who had a Nurse Practitioner's (NP) order, dated 01/14/25, to obtain a urine specimen for suspected urinary tract infection, the Facility failed to ensure that nursing notified the NP when they were unable to obtain the specimen as ordered, to determine next steps or obtain new orders. Resident #1 was transferred and admitted to the hospital on [DATE] and was diagnosed with Urosepsis (a serious complication when the body has a life threatening response to an infection which can lead to organ failure, tissue damage, or death).

Inspectors wroteBased on interviews and records reviewed for one of three sampled residents (Resident #1), who on 1/14/25, had a physician's order for nursing to obtain a urine specimen for a suspected urinary tract infection, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation related to obtaining the urine specimen was incomplete, including but limited to no documentation to support nurses communicated from shift to shift that the urine specimen still needed to obtained.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) whose comprehensive care plan interventions included that he/she required assistance of two staff members and a mechanical lift for transfer due to non-weight bearing status, the Facility failed to ensure staff consistently implemented and followed interventions in his/her care plan, when on 01/12/25, during the evening shift, Certified Nurse Aide (CNA #1) without the assistance of another staff member and a mechanical lift, transferred Resident #1 using a stand/pivot transfer technique, Resident #1 screamed during the transfer and while care was being provided immediately after the transfer. Resident #1 was later diagnosed with a fracture involving the left distal femur (thigh bone) and was transferred to the Hospital Emergency Department (ED) for treatment.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1),who was non-weight bearing, required the assistance of two staff members and a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device (mechanical lift) in a effort to maintain Resident #'1's safety during transfers to prevent incident/accidents resulting in an injury. On 01/12/25, Certified Nurse Aide (CNA) #1, without another staff member or use of the mechanical lift, transferred Resident #1 by herself from his/her wheelchair to bed using stand/pivot transfer, Resident #1 screamed out during the transfer and during care provided by CNA #1 immediately after the transfer, and was later diagnosed with a fracture to his/he left distal femur (thigh bone).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who complained of pain that was new and for whom the Facility had initiated an investigation into an injury of unknown origin. the Facility failed to ensure that it was reported to the Department of Public Health (DPH) within two hours as required, and reported it to the DPH 48 hours later.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to implement infection control practices relative to the use of Personal Protective Equipment (PPE) for one Resident (#96), out of a total sample 19 residents, and provide a sanitary smoking environment for four resident smokers, to prevent the transmission and development of infections. Specifically, the facility staff failed to: 1. Adhere to Enhanced Barrier Precautions (EBP: [...]

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to meet professional standards of practice for one Resident (#98), for three closed records, out of a total sample of 19 residents. Specifically, the facility failed to obtain Physician's orders for the use, management and care of a Thoracic Lumbar Sacral Orthosis (TLSO: brace used to limit movement in the spine) brace for Resident #98, after the Resident suffered a fall with fracture of the spine, and the TLSO brace was being applied by facility staff, placing the Resident at risk for inappropriate use of the TLSO brace and further spinal injury.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two Residents (#13 and #52), out of a total sample of 19 residents. Specifically, the facility staff failed to: 1. For Resident #13, ensure that humidified Oxygen was administered as ordered by the Physician. 2. For Resident #52, ensure that the Oxygen liter flow being administered to the Resident and the range for oxygen saturation (SPO2: measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) levels were not higher than the parameters ordered by the Physician, and putting the Resident at risk of hypercapnia [high carbon dioxide levels in the blood).

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to maintain complete and accurate medical records for one Resident (#48), for three closed records,out of a total sample of 19 residents. Specifically, the facility failed to maintain accurate documentation of meal intake percentage by Certified Nurses Aides (CNAs) when Resident #48 was identified as being at risk for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to conduct regular inspections of all resident bed frames, mattresses, and bed rails as part of a routine maintenance program to identify areas of possible entrapment risks and damaged equipment.

Inspectors wroteBased on record review and interview, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR- screen to determine if a resident has intellectual or developmental disabilities and/or serious mental illness and is in need of further evaluation) for one Resident (#29) out of a total sample of 23 residents, who exceeded the initial 30 days expected facility stay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#407 and #49) out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. Assess Resident #407 for constipation (a condition in which one may have fewer than three bowel movements (BMs) a week; stools that are hard, dry, or lumpy; stools that are difficult or painful to pass; or a feeling that not all stool has passed), implement the facility's bowel protocol, and implement the Physician's orders for treatment of constipation, increasing the risk for fecal impaction (lodgement of dry, hard stool that cannot pass out of the colon or rectum). 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an environment that was free of accidental hazards for one Resident (#40) out of a total sample of 23 residents, relative to medication storage and administration. Specifically, for Resident #40, facility staff left unattended medications at the bedside without determining all medications had been ingested safely and appropriately.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate medical records for one Resident (#59) out of a total sample of 23 residents. Specifically for Resident #59 the facility failed to: 1. Ensure the Resident's most recent Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST- form that indicates a resident's wishes regarding treatments to sustain life) was signed by the Resident. 2. That the Resident's Care Plan accurately reflected the current active MOLST.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure its staff cleaned and disinfected a blood glucose meter/ glucometer (a device that measures blood sugar levels), per device and disinfectant manufacturer's instructions, increasing the risk for transmission of blood borne pathogens on one unit(Nonotuck) out of three units. Review of the Centers for Disease Control and Prevention (CDC) article titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 3/2/11, indicated: whenever possible, blood glucose meter should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. Review of the Evencare G3 blood glucose meter manufacturer's cleaning and disinfecting procedure indicated the meter should be cleaned and disinfected between each patient. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff documented if residents had been offered, received, or declined recommended Pneumococcal immunizations for three Residents (#10, #53, and #87), out of a total sample of five residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that included documentation that three Residents (#53, #86, and #87), out of a sample of five residents had been offered, received, or declined recommended COVID-19 immunizations.