Care One at Peabody

Inspectors wroteBased on observation and interview the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles on three of three units. Specifically, 1. The facility failed to secure drugs and biologicals on three of three units when two treatment carts and one medication room were accessible to the surveyor unsupervised. 2. The facility failed to properly label and store medications in medication carts on two of three units. 3. The facility failed to secure medications in a resident room for one (Resident #90) of 28 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to update the care plan for Activities of Daily Living (ADL) for one Resident (#75) out of a total sample of 28 residents.

Inspectors wroteBased on record review and interview, the facility failed to follow professional standards of practice for one Resident (#494) out of a total sample of 28 residents. Specifically, the facility failed to implement a physician's order to notify provider (physician, nurse practitioner) if Resident #494's daily weight indicated an increase of greater than two pounds.

Inspectors wroteBased on record review and interviews, the facility failed to provide care and services consistent with professional standards including ongoing communication and collaboration with the dialysis facility for one Resident (#536), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of 28 total sampled residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility and failed to implement a Dietitian's recommendation to give phosphate binders (a medication to absorb phosphate from the food you eat to help prevent high phosphorus levels) that was communicated in Resident #536's dialysis communication book. Findings Include: Review of the facility policy titled Hemodialysis Pre and Post Care revised March 2010, indicated the following but not limited to: [...]

Inspectors wroteBased on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs.

Inspectors wroteBased on observation, interview and policy review, the facility failed to provide a dignified dining experience on the second and third floor units.

Inspectors wrote2.) Review of the facility policy titled Assistance with Meals, revised March 2022, indicated the following: - Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. - Facility staff will serve resident trays and will help residents who require assistance with eating. - The nursing staff will prepare residents for eating. Resident #95 was admitted to the facility in December 2021 with diagnoses including dysphagia (difficulty swallowing), unspecified psychosis and anxiety disorder. Review of Resident #95's most recent Minimum Data Set Assessment (MDS), dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure hairnets were worn in the food preparation area, food was labeled, and dented cans of food were not stored with usable cans.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for four Residents (#100, #18, #41, and #61) out of a total sample of 28 residents. Specifically, 1.) For Resident #100, the facility failed to complete daily documentation for Activities of Daily Living (ADLs), 2.) For Resident #18, the facility failed to ensure nursing accurately documented the presence and function of an air mattress, 3.) For Resident #41, the facility failed to ensure a nurse accurately documented a wound dressing as not completed, instead of as completed, and 4.) For Resident #61, the facility failed to ensure a physician's plan of care for liquid protein for wound healing and malnutrition was documented accurately. 1.) Resident #100 was admitted to the facility in April 2023 with diagnoses including depression, anxiety and schizophrenia. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide services that met professional standards of quality to three Residents (#61, #41 and #214) out of a total sample of 28 residents. Specifically, 1.) For Resident #61, the facility failed to transcribe and implement physician's orders for changes in a pressure wound treatment, 2.) For Resident #41, the facility failed to implement a physician's order to apply a dressing to an arterial wound, and 3.) For Resident #214, the facility failed to implement a physician's order to remove sutures.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide appropriate treatment and services related to hearing for two Residents (#91 and #41) out of a total of 28 sampled residents. Specifically, the facility failed to ensure Resident #91 and Resident #41 were ever seen by Audiology services or were provided assistive devices for hearing.

Inspectors wroteBased on observations, policy review, interviews, and record review, the facility failed to ensure nursing provided treatment and services consistent with professional standards of practice to promote healing and prevent development of new pressure ulcers for two Residents (#18 and #71), out of 28 total sampled Residents. Specifically, 1a.) For Resident #18, the facility failed obtain a physician order to discontinue a dressing for a recently healed pressure ulcer. 1b.) For Resident #18, the facility failed to obtain a physician order to discontinue an air mattress ordered for skin integrity management. 2.) For Resident #71, the facility failed to ensure an air mattress was at the correct settings for a Resident with multiple pressure ulcers.

Inspectors wroteBased on observations, policy review, record review and interviews, the facility failed to identify and provide interventions for a decrease in range of motion for one Resident (#5) out of a total sample of 28 residents.

Inspectors wroteBased on record review, interview and policy review the facility failed to maintain acceptable parameters of nutrition status for two Residents (#69 and #29) out of a total sample of 28 residents. Specifically, 1.) For Resident #69, the facility failed to identify and put an intervention in place for a significant weight loss, and 2.) For Resident #29, the facility failed to identify and address a potential significant weight loss by not reweighing the Resident in a timely manner to confirm a significant weight loss.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two Residents (#49 and #69) out of a total sample of 28 Residents.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error when his/her admission Physician Order for Metoprolol, (medication used to treat high blood pressure) was not transcribed into his/her Medication Administration Record (MAR) and as a result, he/she was not administered the medication for several days. Findings Include: The Facility Policy titled Adverse Consequences and Medication Errors, dated as revised February 2023, indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with Physician's Orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. [...]