Care Village at Mattapan

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required 1) anticonvulsant medication for epilepsy (seizure disorder) and 2) an anticoagulant (blood thinner) for a newly diagnosed deep vein thrombosis (DVT, blood clot), the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility, his/her medication orders were not accurately reconciled by nursing resulting multiple missed doses of both medications. Resident #1 was observed experiencing seizure activity, was transported to the Hospital Emergency Department for evaluation and was admitted for treatment.

Inspectors wroteBased on interviews and records reviewed, the facility failed to implement an effective antibiotic stewardship program that included accurate and complete tracking and monitoring of antibiotic use. Specifically, the facility's antibiotic stewardship documentation was incomplete and did not accurately reflect residents with active antibiotic orders, and the facility was unable to demonstrate consistent monitoring, analysis, or reporting of antibiotic utilization in accordance with regulatory requirements.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents on two of two units. Specifically, the facility failed to ensure resident rooms and common areas were maintained in good repair and sanitary condition and failed to consistently identify and correct environmental concerns through routine environmental rounds.

Inspectors wroteBased on observation and interviews, the facility failed to ensure concerns reported during the Resident Council related to call light responses were thoroughly documented and acted upon timely.

Inspectors wroteBased on observation, record review and interview, the facility failed to alert the physician and the behavioral health provider of an increase in sexually inappropriate behaviors for one Resident (#8) out of a total of 18 sampled Residents.

Inspectors wroteBased on record review and interview the facility failed to report an allegation of verbal abuse to the State Agency for one Resident (#24) out of 18 sampled residents. Specifically, an allegation of verbal abuse was submitted to the facility on 2/11/26 but not reported to the State Agency until 2/18/26.

Inspectors wroteBased on record review and interview the facility failed to investigate an allegation of verbal abuse for one Resident (#24), out of 18 sampled residents. Specifically, a Family Member reported an allegation of verbal abuse to the facility on 2/11/26, but an investigation did not begin until 2/18/26; approximately seven days later.

Inspectors wroteBased on observation and interview, the facility failed to secure medications for one of two medication storage areas. Specifically, the second floor medication cabinet was unlocked and medications were accessible to staff, residents and visitors.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure two of two nourishment kitchens were maintained in a clean, sanitary condition and failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document a urinary catheter change.

Inspectors wroteBased on observations, record review and interview, the facility failed to meet professional standards of practice for five Residents (#46, #43, #20, #42 and #11) out of a total sample of 23 residents. Specifically: 1. For Resident #46, the facility failed to follow a physician's recommendation to send the resident to an outside clinic. 2. For Resident #43, the facility failed to obtain a physician's orders for air mattress settings 3. For Resident #20, the facility failed to obtain a physician's orders to hold a tube feeding when the Resident was away from the facility. 4. For Resident #42, the facility failed to follow physician's orders regarding air mattress settings. 5. For Resident #11, the facility failed to implement physician's orders for heel booties and elevating heels off the mattress.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was labeled in the main kitchen refrigerators, and that dented cans were not accepted into storage/circulation.

Inspectors wroteBased on record review and interview the facility failed to maintain accurate and complete medical records for four Residents (#46, #43, #3 and #20) out of a total sample of 23 residents. Specifically, 1. For Resident #46 the facility failed to maintain an accurate diagnosis list. 2. For Resident #43 the facility failed to document the appropriate location of a blood pressure measurement. 3. For Resident #3 the facility failed to ensure that the medical record included information pertaining only to that resident. 4. For Resident #20 the facility failed to accurately document the intake of enteral feeding per day.

Inspectors wroteBased on observation and interview, the facility failed to provide a dignified existence for one Resident (#3) out of a total sample of 23 residents. Specifically, staff failed to pull the privacy curtain or shut Resident #3's door when he/she was in bed without a top on, which exposed Resident #3 to others passing by in the hallway.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the physician of a change in condition related to edema for one Resident (#19) out of a total sample of 23 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment for one Resident (#3) out of a total sample of 23 residents.

Inspectors wroteBased on record review and interviews, the facility failed to investigate a report of drug and alcohol use in the facility, reported by one Resident (#44), out of a total sample of 23 Residents. Findings Include: Review of the facility policy titled, Abuse Prohibition, revised 2/20/23, indicated the following: Policy -Allegations of abuse will be reported and thoroughly investigated. -The Administrator and Director of Nursing are responsible for investigation and reporting. Investigation -The investigation will begin immediately after reporting the actual or suspected incident. -Initiate the investigative process using factual data. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewed and have information regarding the allegation. -The results of the investigation will be documented. [...]

Inspectors wroteBased on record review and interviews for two Residents (#49 and #67) of 23 sampled residents, the facility failed to ensure staff adequately identified a significant change in the Resident's status and completed a comprehensive Significant Change of Status Assessment Minimum Data Set (MDS) as required. Specifically 1. For Resident #49, the facility failed to identify and complete Significant Change in Status MDS when Resident #49, experienced significant weight loss, had an indwelling urinary catheter removed, and developed a stage 4 pressure wound. 2. For Resident #67, the facility failed to complete a significant change in status MDS when Resident #67 was signed on to hospice care.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately reflect the status of one Resident (#42) out of a total sample of 23 residents, when the Minimum Data Set (MDS) assessment failed to indicate that the Resident had an indwelling urinary catheter.

Inspectors wroteBased on record review and interview the facility failed to create a baseline plan of care within the required 48 hours of admission for one Resident (#373) out of a total sample of 23 residents.

Inspectors wroteBased on observations, record review and interview the facility failed to develop and implement a comprehensive resident-centered care plan for one Resident (#371) out of a total sample of 23 residents. Specifically, for Resident #371 the facility failed to develop a care plan for dialysis and for an actual skin impairment.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for one Resident (#28) out of a total sample of 23 residents. Specifically, for Resident #28 the facility failed to provide assistance and/or supervision with meals.

Inspectors wroteBased on observation, record review, and interview, the facility failed to address a change in condition related to edema management for one Resident (#19) out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure that one Resident (#58) out of a total sample of 23 residents received proper treatment and assistive devices to maintain their vision. Specifically, the facility failed to ensure that Resident #58 had a follow up and consultation for cataract surgery as recommended by the consulting eye doctor.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and services consistent with professional standards of practice by not following a physician's order for air mattress settings to promote the healing of existing pressure ulcer for one Residents (#20), out of a total sample of 23 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine) for one Resident (#20) out of a total sample of 23 residents. Specifically, the facility failed to implement the enteral feeding in accordance with the physician's order to receive the enteral feeding for 24 hours per day.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#3 and #11), out of a total sample of 23 residents. Specifically, 1. For Resident #3, the facility failed to label and date the oxygen tubing and maintain a clean oxygen filter. 2. For Resident #11, the facility failed to label and date nebulizer tubing and store it in properly in a bag.

Inspectors wroteBased on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#28) out of a total sample of 23 residents. Specifically, for Resident #28, the facility failed to ensure a psychiatric consult was completed. Findings Include: Resident #28 was admitted to the facility in December 2024 with diagnoses that included dementia without behaviors, dysphagia, and schizophrenia. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a six out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating severe cognitive impairments. Further review of the MDS indicated the Resident is receiving an antipsychotic medication. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure residents were free of unnecessary medications and were properly assessed for possible adverse reactions to psychotropic medications for one Resident (#28) out of a total of 23 sampled residents. Specifically, for Resident #28, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings Include: According to CMS guidelines, an AIMS (Abnormal Involuntary Movement Scale) test should be conducted on a nursing home resident when a resident starts or has significant changes to medications that can cause tardive dyskinesia, like certain antipsychotics. [...]

Inspectors wroteBased on observation and interview, the facility failed to adhere to infection control practices and standards increasing the risk of contamination and spread of infection for residents in the facility. Specifically, the facility failed to unglove hands after bagging soiled linens and proceeded to wear the contaminated gloves in the hallway and potentially contaminate the soiled linen chute.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for four Residents (#3, #4, #15, and #13) that care plans were implemented, out of a total sample of 24 residents. Specifically: 1. For Residents #3, #4 and #15, the facility failed to provide supervision with meals, per the plan of care. 2. For Resident #13, the facility failed to ensure his/her call light was within reach, per the plan of care.

Inspectors wroteBased on observation, record review and interview for three Residents, (#37, #7, #30) out of a total of 24 sampled residents, the facility failed to implement interventions for the prevention and treatment of pressure ulcers. Specifically: 1. For Resident #37, the facility failed to implement the Wound Physician's order for a wound dressing. 2. For Resident #30, who had actual skin breakdown, the facility failed to consistently implement the physician's orders for an air mattress, prevalon boots and heel offloading to prevent further skin breakdown/decline. 3. For Resident #7, the facility failed to implement the Wound Physician's order to offload heels.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) ensure medication carts were locked and secured on one of two units, 2.) ensure medications were labeled and stored according with manufacture's guidelines, and 3.) ensure the medication cart keys were not left unattended.

Inspectors wroteBased on observation, record review and interview the facility failed to adhere to professional standards of practice to prevent possible infections. Specifically, the facility failed to: 1. Doff (remove) personal protection equipment properly and failed to perform hand hygiene. 2. Ensure nursing disinfected a glucometer (device that measure how much sugar is in a blood sample) according to manufactures guidelines.

Inspectors wroteBased on record review and interview the facility failed to ensure two of three Certified Nursing Assistant educational files reviewed had no less than 12 hours of in-service training per year.

Inspectors wroteBased on observation, record review and interview the facility failed to 1. speak respectfully to one Resident (#14) and 2. staff failed to respect the resident environment as evidenced by using cell phones and conducting private conversations in a resident area, from a total sample of 24 residents. Findings Include: Review of the facility policy Dignity/Quality of Life dated 12/6/21, indicated: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Procedure: - Residents shall always be treated with dignity and respect. - Staff shall always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the residents by his or her room number, diagnosis, or care needs. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to file a grievance for one Resident (#14) out of a total sample of 24 residents. Findings Include: Review of the facility policy titled Grievances/Concerns, dated as last revised December 2021, indicated the following: Policy: -Residents or their representatives may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, lost clothing, etc. Employees of the facility will assist residents and or their representatives in the grievance/complaint process when such requests are made. Procedure: -Grievances/concerns may be submitted orally or in writing. The person/staff receiving an oral grievance/concern will fill out the grievance/concern form for submission to leadership. [...]

Inspectors wroteBased on record review, policy review and interviews, the facility failed to implement their abuse prohibition policy for three Residents (#39, #25, and #10) out of a total sample of 24 residents. Specifically, 1. For Resident #39 and #25, the facility failed to ensure nursing immediately reported an allegation of potential abuse (resident to resident altercation) to the Director of Nursing or Administrator, as required. 2. For Resident #10, failed to ensure nursing immediately reported an allegation of potential abuse to the Director of Nursing or Administrator, as required.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to report an injury of unknown source to the state agency within two hours, as required for one Resident (#10) out of a total sample of 24 residents. Specifically, on 7/14/23 at 1:50 P.M., the Director of Nursing (DON) was made aware of Resident #10's new pain and diagnosis of an angulated supracondylar fracture of the femur. The DON did not report this injury to the state agency until 7/19/23 at 3:43 P.M., almost 120 hours after becoming aware of the new fracture.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to thoroughly investigate an injury of unknown origin and failed to maintain evidence of a thorough investigation was completed for one Resident (#10) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#10), out of a total sample of 24 residents. Specifically, the facility staff failed to review and revise the Resident #10's care plans with the IDT after each Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to follow professional standards of practice for two Residents (#30 and #39), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #30, the facility failed to implement the physician's order for seizure pads. 2. For Resident #39, the facility failed to ensure staff had supporting testing to diagnosis paranoid schizophrenia and who was receiving antipsychotic medication.

Inspectors wroteBased on observation, record review and interview for two Residents (#41 and #30), out of a total sample of 24 residents, the facility failed provide activities of daily living in accordance with their plan of care. Specifically: 1. For Resident #41, the facility failed to provide incontinence care and positioning in accordance with the plan of care. 2. For Resident #30, the facility failed to provide meals in accordance with physician's orders and the plan of care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one Resident (#39), out of a total sample of 24 residents received proper care and treatment to maintain good foot health.

Inspectors wroteBased on observations, record review and interviews, for one Resident (#25) out of a total sample of 24 residents, the facility failed to ensure staff provided adequate supervision to maintain safety. Specifically, for Resident #25, the staff knowingly allowed Resident #25 to keep his/her own smoking materials, including a lighter, and allowed Resident #25 to smoke unsupervised between designated supervised smoking times. Findings Include: Review of the facility's policy titled Smoking, dated 5/26/2022, indicated the following: Policy: It is the policy of this facility to maintain a safe resident smoking/nicotine environment. This policy respects resident's rights and preferences and is in accordance with Life Safety Code requirements, and state and local laws governing safe practices for the facility. [...]

Inspectors wroteBased on record review, policy review and interviews, the facility failed to identify and address a significant weight gain for one Resident (#39) out of a total sample of 24 Residents. Specifically, for Resident #39 on 2/28/24, the Resident weighed 157.4 pound (lbs) and on 2/29/24, the Resident weighed 172.2 pounds which is a 9.40 % gain.

Inspectors wroteBased on observation, record review and interview for one Resident (#37) out of three applicable residents in a total sample of 24 residents, the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach or small intestine). Specifically, the facility failed to implement the physician's order for continuous feed, failed to notify the physician or nurse practitioner the continuous feed was not implemented and failed to obtain orders for an alternate way to support Resident #37's nutritional needs.

Inspectors wroteBased on record reviews and interviews, for one Resident (#25), out of a total sample of 24 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #25, with a known history of trauma and mental illness, the facility failed to provide services to include psychotherapy.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to act upon recommendations made by the consultant pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#10), out of a total sample of 24 residents. Specifically, the facility failed to ensure the 11/29/23, 12/25/23, 1/25/24, and 2/26/24 consultant pharmacist's recommendations were acted upon.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that each Resident's drug regimen was free from unnecessary psychotropic medications for one Resident (#10), out of a total sample of 24 residents. Specifically, for Resident #10, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were accurate for two Residents (#63, #30) out of a total of 24 sampled Residents. Specifically: 1. For Resident #63, the facility failed to ensure his/her code status was accurate. 2. For Resident #30, the facility failed to ensure nursing maintained complete and accurate comprehensive weekly skin checks.

Inspectors wroteBased on observation, record review and interview for one Resident (#41), out of a total sample of 24 residents, the facility failed to ensure a coordinated person-centered care plan with individualized interventions was developed for the provision of hospice care services.

Inspectors wroteBased on record review and interview, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan related to the accuracy of resident code status. Specifically, the facility identified inconsistencies in the accurate documentation of advanced directives on [DATE] but failed to conduct a facility-wide Performance Improvement Project or to monitor for lapses. Subsequently, staff failed to provide Cardiopulmonary Resuscitation (CPR) to one Resident (#63) who had an incomplete MOLST form and therefore, continued as a full code status.

Inspectors wroteBased on record review and interview, the facility failed to inform three out of three Residents, or their representative, of the potential liability for payment for non-covered services including estimated cost of services.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure nursing staffing data, including the total number and actual hours worked by following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily in a prominent area and readily accessible to residents and visitors as required.

Inspectors wroteBased on record review and interview for two Residents (#28, #37) out of 24 sampled residents, the facility failed to complete a notice of intent to transfer/discharge to the hospital.

Inspectors wroteBased on observation, record review and interview for two Residents (#37, #28) out of 24 sampled residents, the facility failed to provide bed hold notices upon transfer to the hospital.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at increased risk for elopement and exhibited exit seeking behaviors, the Facility failed to ensure they provided adequate safety equipment, specifically that facility emergency exit doors located at the far end of each unit, were equipped with alarms that sounded at levels loud enough for staff to be able to hear alarms from anywhere on the unit and therefore respond appropriately in an effort to maintain resident safety to prevent an incident of elopement. On [DATE], Resident #1 successfully eloped from the Facility through an emergency exit door unbeknownst to staff, and although the emergency exit door alarm sounded, staff did not hear or respond to the alarm because of it's low volume setting.