Foremost at Sharon LLC

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who developed Moisture-Associated Skin Damage (MASD) to his/her coccyx, the Facility failed to ensure they notified his/her Physician of the Wound Nurse Practitioner's recommendations for wound care and as a result, the treatment recommendations were never implemented.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident # 1), who developed a wound to his/her coccyx and required wound care, and required a sling to his/her left arm due to a fractured left clavicle, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed, ) his/her wound care needs and 2) care and monitoring needs related to his/her fractured left clavicle.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who developed an open area to his/her coccyx and sustained a fracture to his/her left clavicle after a fall, the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice when 1) he/she was not seen by the facility's Wound Nurse Practitioner in a timely manner and 2) treatment orders from the Hospital Emergency Department (ED) related to the left clavicle fracture were not implemented.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed an open area to his/her coccyx, and was non-weight bearing, required the use of a sling and monitoring by nursing due to a left clavicle fracture, the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was no nursing documentation related to his/her coccyx wounds characteristics and progress towards healing and 2) there was no nursing documentation on his/her Treatment Administration Record (TAR) or Nurse Progress Notes to support nursing monitored Resident #1's left arm per Hospital Discharge Summary recommendations. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop effective interventions to prevent nine falls for one Resident (#26), out of a total sample of 15 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment for three Residents (#1, #19, and #24), out of a sample of 15 residents. Specifically, the facility failed to: 1. For Residents #1 and #19, complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattresses, placing the Residents who had limited mobility and utilized bilateral side rails, at risk for possible entrapment; and 2. For Resident #24, to ensure the mattress bolster/extender (an object used to fill gaps between the mattress and footboard of a bed) was in place to fill the gap between the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of Buspirone (anti-anxiety), Trazodone (antidepressant also used to treat anxiety) and Sertraline (selective serotonin reuptake inhibitor used to treat anxiety) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment.

Inspectors wroteBased on interviews and record review, for one Resident (#26), of 15 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #26, the facility failed to initiate replacement of a broken/missing partial upper denture timely.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) when the Resident was identified as having wounds on his/her right foot.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#23), out of a total sample of 18 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to implement treatments as ordered and notify the physician of worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit).

Inspectors wroteBased on observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents, the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to: [...]

Inspectors wroteBased on document review and interview, 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: 1. Ensure a water management program was implemented to minimize the risk of Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic pathogens in building water systems by accurately measuring and documenting water temperatures; 2. For Resident #211, ensure staff wore personal protective equipment (PPE) and perform hand hygiene as required for Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); and 3. [...]

Inspectors wroteBased on document review and interview, the facility failed to ensure their arbitration agreement provides for the selection of a neutral venue that is convenient to both parties.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to notify the Resident's Physician/Physician extender about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#23), from a total sample of 18 residents. Specifically, the facility failed to notify the physician/physician extender of the deterioration of moisture-associated skin damage (MASD-caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) on the Resident's left buttock to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) and the Wound Consultant's treatment recommendations, resulting in a delay of treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for one Resident (#23), in a total sample of 18 residents. Specifically, the facility failed to ensure the MDS accurately reflected the Resident's pressure ulcer risk.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#23), out of a total sample of 18 residents. Specifically, for Resident #23, the facility failed to ensure the comprehensive care plan was revised to reflect a newly developed Stage 2 pressure ulcer (PU- partial thickness skin loss with exposed dermis) and a change in treatment.

Inspectors wroteBased on record review and interview, the facility failed to implement the Physician's order to monitor blood glucose levels three times per day before meals for one Resident (#34), out of a sample of 18 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Borderland) of three units in the facility. Specifically, the facility failed to ensure a storage closet and storage area in the shower room was securely locked and hazardous items were not easily accessible to wandering residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to monitor adverse consequences of an anticoagulation medication (used to prevent the blood from clotting, a blood thinner) prescribed for one Resident (#34), out of a total sample of 18 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure the drug regimen was free from unnecessary psychotropic medications for one Resident (#34), out of a total sample of 18 residents. Specifically, the facility failed to monitor Resident #34 for potential adverse consequences and behaviors when administering antidepressant medication.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#29 and #1), out of four residents observed.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. For Resident #51, ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside; 2. Ensure the medication and treatment carts were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice.

Inspectors wroteBased on document review and interview, the facility failed to implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to maintain a bladder scanner (a noninvasive tool used to measure urine volume in the bladder) to aid in the assessment of urine volume in the bladder resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure the dish machine operated at the required temperatures to ensure all dishes, utensils, and cookware were properly cleaned and sanitized in order to prevent illness.

Inspectors wroteBased on observation and interview, the facility failed to properly maintain the garbage storage area located behind the facility resulting in a vast debris field in the surrounding wooded area.

Inspectors wroteBased on record review, policy review, interview, and observation, the facility failed to maintain professional standards of practice for three Residents (#10, #26 and #16), out of a total sample of 16 residents. Specifically, the facility failed: 1. For Resident #10, to ensure fingersticks (a procedure to test the glucose level using a small amount of capillary blood from the finger) were completed as ordered; 2. For Resident #26, to obtain an order, in a timely manner, for the use of a wander guard monitoring device; and 3. For Resident #16, a. To provide safe medication administration, by leaving medications at the bedside unattended, and b. To maintain a standard expectation of administering medications within one hour of the physician's ordered time.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan for wound care for one Resident (#26), out of a total sample of 16 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement recommendations for a dementia medication for Resident (#26) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 16 residents. Specifically, the facility failed to address and implement the Psychiatric Nurse Practitioner's (PNP) recommendations to start Namenda, a medication which has been shown helpful with both delaying memory loss and reducing associated anxiety.

Inspectors wroteBased on observation and interview, the facility failed to ensure that staff securely stored medication on the Dementia Special Care Unit (DSCU).

Inspectors wroteBased on record review, interview, and policy review, the facility failed to obtain ordered labs in a timely manner for one Resident (#10), out of a total sample of 16 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to maintain a complete accurate medical record for two Residents (#56 and #44), out of a total sample of 16 residents plus three closed records reviewed. Specifically, the facility failed to: 1. Maintain a complete closed medical record containing medication regimen review recommendations for Resident #56; and 2. Ensure a discharge order was in place for Resident #44 prior to discharge from the facility.

Inspectors wroteBased on record review, interview, and observation, the facility failed for two Residents (#51 and #26), out of a total sample of 16 residents, to ensure the Minimum Data Set (MDS) assessment was completed accurately. Specifically, the facility failed: 1. For Resident #51, to ensure accuracy when coding for a urinary catheter; and 2. For Resident #26, to reflect known falls since admission.