Care Village at West Roxbury

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed for two Residents (#59, #) out of a total sample of 19 residents. Specifically,For Resident #46, the facility failed to ensure a resident- centered personalized care plan was developed for a pacemaker. For Resident #59, the facility failed to ensure a resident-centered personalized care plan was developed for a pacemaker.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide a dignified dining experience for one Resident (#46) out of a total sample of 19 Residents. Specifically, facility staff stood over the Resident in bed while assisting with meals.

Inspectors wroteBased on observations, interview and record review the facility failed to assess the use of a seat belt as a potential restraint for one Resident (#17) out of a total sample of 19 Residents.

Inspectors wroteBased on record review and interview the facility failed to ensure that for one Resident's (#46) out of a total sample of 19 residents, their drug regime was free from unnecessary antipsychotic drugs. Specifically, the facility failed to adequately monitor the use of quetiapine (an antipsychotic medication) and evaluate whether a Gradual Dose Reduction (GDR) was indicated.

Inspectors wroteBased on record review and interview, the facility to ensure that services provided met professional standards for one Resident (#46) out of a total sample of 19 residents. Specifically, for Resident #46 the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission and at the initiation of an antipsychotic medication.

Inspectors wroteBased on record review and interviews the facility failed to develop person centered trauma informed care plans accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for two Residents (#10 and #34) out of a sample of 19 Residents. Specifically, the facility failed to develop person centered (Post Traumatic Stress Disorder) PTSD care plans.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health services for one Resident, (#46) out of a total of 19 sampled Residents. Specifically, the facility failed to ensure behavioral health services were provided for Resident #46 who received antipsychotic medication, antidepressant medication and has diagnoses of anxiety and major depressive disorder.

Inspectors wroteBased on record review and interview the facility failed to ensure for two Residents (#46 and #2), out of a total sample of 19 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations. Specifically,For Resident #46, the facility failed to implement recommendations timely to complete an AIMS (abnormal involuntary movement scale) Assessment, clarify the frequency of administration for as needed orders, and the pharmacist failed to recommend a Gradual Dose Reduction (GDR) for an antipsychotic medication. For Resident #2 the facility failed to clarify the frequency of administration for an as needed order.

Inspectors wroteBased on observation and interview the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the medications on one of two units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#52) did not self-administer medications out of a total sample of 17 residents. Specifically, Resident #52 was not assessed to be able to safely self-administer medication and was observed self-administering medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status of one Resident (#25) out of a total sample of 17 residents. Specifically, for Resident #25 the facility failed to code the correct pressure ulcer stage, when there was documentation of granulation.

Inspectors wroteBased on observation, record review, and interviews, for two Residents (#217 and #62) of 17 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, 1.) For Resident #217, the facility failed to ensure nursing implemented a physician's ordered urinary catheter drainage bag change as ordered by the physician. 2.) For Resident #62, the facility failed to follow physician's orders to apply offloading booties to bilateral heels while in bed.

Inspectors wroteBased on observations, record review, and interview the facility failed to provide respiratory care services in accordance with professional standards of practice for one Residents (#61) out of a total sample of 17 residents. Specifically, for Resident #61, the facility failed to ensure nursing consistently implemented his/her physician's ordered continuous positive airway pressure machine (CPAP, a machine that uses mild pressure to keep the breathing airways open during sleep, used to treat obstructive sleep apnea).

Inspectors wroteBased on record review and interview, the facility failed to develop plans of care for their diagnoses of post-traumatic stress disorder for two Residents (#17 and #29) out of a total sample of 17 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that bed rails were implemented in accordance with the bed rail assessment and physician's order, for one Resident (#28) out of a total sample of 17 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed by the facility in a timely manner for one Resident (#28) out of a total sample of 17 Residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all medications used in the facility were stored in accordance with accepted professional principles of practice. Specifically, the facility failed to ensure nursing properly stored medications on one of two nursing units observed ([NAME] Unit).

Inspectors wroteBased on observation and interview, the facility failed to date refrigerated foods and dispose of expired refrigerated food as required.

Inspectors wroteBased on record review, interview, and observation for two Residents (#47 and #25), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to: 1.) For Resident #47, the facility failed to accurately document a treatment for steri strips. 2.) For Resident #25 the facility failed to ensure nursing completed a wound description on an admission assessment and weekly skin check.

Inspectors wroteBased on observations and interviews, for two of two resident units, the Facility failed to ensure they maintained a clean and homelike environment for resident use, when the showers rooms on both units were found to have dirty tile grout, the shower room on one unit had missing floor tiles, the drain cover was missing, and there were flying insects hovering around the open drain.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure they supported each residents' right to self determination which included facilitating the resident's choice to smoke, when the Facility permanently revoked Resident #1's smoking privileges and refused to allow Resident #1 to join other residents who smoke during the Facility's supervised smoking times.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure Resident #1 was free from physical restraint when, on 5/20/24 around 5:40 A.M., Nurse #1, Certified Nurse Aide (CNA) #1 and CNA #2 used physical force to confiscate a vape pen (an electronic handheld device consisting of a battery attached to a cartridge filled with a liquid solution that is vaporized and simulates tobacco smoking) from Resident #1, which he/she had hidden under his/her clothing.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when, on 5/20/24 around 6:00 A.M., Certified Nurse Aide (CNA) #2 told Nurse #1 that Resident #1 alleged that they (CNA #1, CNA #2 and Nurse #1) had assaulted him/her, however Nurse #1 did not immediately report the allegation to the Administrator. As a result, the Administrator only became aware of the allegation after police officers arrived at the Facility in response to Resident #1's call to them, which was more than five hours after the incident occurred and after CNA #2 had made Nurse #1 aware of Resident #1's allegation.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure staff treated him/her in a dignified and respectful manner, when it was reported that on 04/29/24, Certified Nurse Aide (CNA) #1 engaged in a verbal altercation with Resident #1 that included the use of profane language.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure four Residents (#8, #13, #53 and #28) were provided a dignified existence, out a total sample of 25 residents. Specifically, 1) For Residents #8 and #13 the facility failed to provide facial hair removal, and 2) For Residents #53 and #28 the facility failed to serve their meals in a timely manner.

Inspectors wroteBased on interview, record review and observations the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to five Residents (#2, #14, #50, #28,#16), out of a total sample of 25 residents. Specifically, the facility failed to provide assistance with meals for dependent residents for five Residents (#2, # 14, #50, #28, #16).

Inspectors wroteBased on record review and interview the facility failed to develop a plan of care for Post Traumatic Stress Disorder (PTSD) for two Residents (#60 and #21) who had an active diagnosis for PTSD out of a total sample of 25 Residents.

Inspectors wroteBased on observation and interview the facility failed to 1. implement infection prevention and control practices during dining in one of two dining rooms and 2. failed to ensure housekeeping staff maintained infection control practices on one of two units.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#21) was assessed for the ability to self-administer medications out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure hoyer pads were available for one Resident (#51) out of a total of 25 sampled Residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the hospital discharge recommendations for one Resident (#52) out of a total sample of 25 residents. Specifically, the facility failed to identify a weight gain of two pounds or more in one day after the Resident received cardiac surgery.

Inspectors wroteBased on observation, record review and interview, the facility failed to complete fall assessments after each documented fall for one Resident (#16) out of a total sample of 25 Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff changed a catheter as needed for one Resident (#7) out of a total of 25 sampled Residents.

Inspectors wroteBased on observation and record review, the facility failed ensure tube feedings (TF) infused as ordered for one Resident (#46) out of a total of 25 sampled Residents.

Inspectors wroteBased on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. change and clean the oxygen filters for one Resident (#58) and 2. failed to ensure one Resident (#52) was following physician's orders out of a total sample 25 residents.

Inspectors wroteBased on observation, policy review and interview the facility failed to provide for the management of dialysis emergencies including procedures for medical complications, and for equipment and supplies necessary to manage a medical emergency for one Resident (#2) out of a total sample of 25 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure that 1. a treatment cart was locked on the [NAME] unit, 2. that medications were stored properly on one of two units and 3. medications were securely stored for one Resident (#21) out of a total sample of 25 Residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure requests for dentures were followed up for one Resident (#7) out of a total of 25 sampled Residents.