Highland Park Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards of practice for five Residents (#182, #7, #127, #20 and #90) out of 37 total sampled residents. Specifically,1. For Resident #182, the facility failed to complete liver function tests and a basic metabolic panel as ordered.2. For Resident #7 the facility failed to ensure weekly skin checks were completed.3. For Resident #127 the facility failed to ensure weekly skin checks were completed.4. For Resident #20 the facility failed to ensure weekly skin checks were completed as indicated in physician's orders.5. For Resident #90 the facility failed to implement a physician treatment order for a cheek wound.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding Included:Review of the facility policy titled Minimum Staffing-Massachusetts, undated, indicated the following:-On or after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day of 3.580 hours, of which at least 0.508 hours must be care provided to each resident by a registered nurse.-The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD. Review of the facility assessment indicated the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary and comfortable environment on three of four resident floors. Specifically, the facility failed to:Maintain and replace stained and bowed ceiling tiles in resident hallways on the third, fourth and fifth floors. Patch holes in walls in resident bedrooms.

Inspectors wroteBased on record review, interview and observation, the facility failed to implement the contracted Pest Control Company's recommendations to make repairs for the control of mice and cockroaches on three of four resident floors.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a dignified existence for one Resident (#78) out of a total sample of 37 residents. Specifically, for Resident #78, the facility failed to remove unwanted facial hair.

Inspectors wroteBased on observation, record review and interview, the facility failed to accommodate the needs of one Resident (#20) out of a total of 37 sampled residents. Specifically, the facility failed to provide a wheelchair or other seating able to fit Resident #20, resulting in Resident #20 being unable to get out of bed.

Inspectors wroteBased on observation, record review and interview, the facility failed to promote resident rights to make choices about aspects of his/her life in the facility that are significant for one Resident (#134) out of a total of 37 sampled Residents. Specifically, the facility failed to allow Resident #134, an alert and oriented resident who is responsible for their own decision making, to leave the premises independently.

Inspectors wroteBased on record review and interviews, the facility failed to formulate an advance directive for one Resident (#85) out of a sample of 37 Residents. Specifically, the facility failed to include an antipsychotic medication in a [NAME] treatment plan (a court-approved, legally mandated document authorizing a guardian to make decisions about extraordinary medical treatment, primarily antipsychotic medication for an incapacitated person who cannot consent to their own care).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in the resident's mental health. Specifically, for Resident #8, the facility failed to notify the physician of vocalized suicidal ideations.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for one Resident (#127) out of a total sample of 37 Residents. Findings Include:Review of facility policy titled Use of Restraints, dated as revised April 2017, indicated the following:-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.-Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a plan of care for two Residents (#8 and #175) out of 37 residents. Specifically:For Resident #8 the facility failed to develop a plan of care for the vocalization of suicidal ideations. For Resident #175 to facility failed to implement a plan of care for assist with eating.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two Residents (#148 and #105), who are unable to carry out activities of daily living, received the necessary services to maintain good grooming and hygiene out of a total sample of 37 residents. Specifically,1. For Resident #105 the facility failed to provide incontinence care as indicated in the plan of care. 2. For Resident #105 the facility failed to remove unwanted facial hair.3. For Resident #148 the facility failed to provide nail care.

Inspectors wroteBased on observation, record review and interview the facility failed to implement treatment orders as recommended by the Wound Physician for one Resident (#173) out of a total of 37 sampled residents. Specifically, the facility failed to implement hydrogel orders for Resident #173's skin tear timely.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#3) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 37 residents. Specifically, for Resident #3 the facility failed to implement recommendations from the Wound Doctor.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nursing implemented a splinting device as ordered for contracture prevention for one Resident (#148) out of a total sample of 37 residents. Specifically, the facility failed to ensure Resident #148 was wearing a hand roll as ordered and recommended by the therapy department.

Inspectors wroteBased on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,The facility failed to ensure treatment carts were locked while a nurse was not present on two out of four unitsThe facility failed to ensure nursing staff stayed with the surveyors while doing the medication storage task on two out of four units.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure six Residents (#12, #70, #88, #146, #77 and #94) received care in accordance with professional standards of practice, out of a total sample of 33 residents. Specifically, 1. For Resident #12, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 2. For Resident #70, the facility failed to ensure nursing completed weekly skin assessment per the physician order. 3. For Resident #88, the facility failed to ensure nursing obtained a physician order for the use of his/her air mattress. 4. For Resident #146, the facility failed to ensure nursing applied ace wraps as per the physician's order. 5. For Resident #77, the facility failed to ensure staff applied a palm guard as per the physician's order. 6. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were addressed timely for three Residents (#21, #68, and #3) out of five residents reviewed, out of a total sample of 33 residents.

Inspectors wroteBased on observations, record review, and interviews the facility failed to implement the infection prevention and control program. Specifically: 1. The facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff. 2. The facility failed to ensure staff appropriately donned (put on) a precaution gown while performing wound care for a Resident on enhanced barrier precautions (EBP). 3. The facility failed to ensure staff performed appropriate hand hygiene after removing gloves during wound care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff provided care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing resident individuality for two sampled Residents (#68 and #119) out of a total of 33 sampled residents. Specifically, the facility failed to ensure staff regularly communicated with Resident #68 and Resident #119 in a language they understand.

Inspectors wroteBased on interviews and observations, the facility failed to provide three Residents (#84, #7 and #67) of 33 sampled residents with the choice of an alternate meal.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#155) out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed accurately complete the Minimum Data Set Assessments (MDS) for two Residents (#68 and #119) out of a total of 33 sampled residents. Specifically, the facility failed to attempt to utilize interpreter services to complete interviews for Resident #68 and Resident #119 to assess for cognition in section C of the MDS.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) for two Residents (#21 and #160) out of a total sample of 33 residents. Specifically, 1. For Resident #21, the facility failed to provide necessary nail care. 2. For Resident #160, the facility failed to ensure the Resident maintained good oral hygiene when staff did not ensure supervision with oral hygiene was provided, as indicated in the care plan, and the Resident was not provided with a toothbrush.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the necessary care and treatment for one Resident (#141) out of a total of 33 sampled residents. Specifically, the facility failed to notify the physician and implement recommendations made by the orthopaedic (a branch of medicine specializing in diagnosing and treating conditions related to the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) specialist for pain management, the use of splints and occupational therapy services.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure treatments related to pressure ulcers were implemented per the physicians orders for one Resident (#21) out of a total of 33 sampled residents. Specifically, the facility failed to a.) ensure Resident #21's air mattress was at the correct setting and b.) ensure the Wound Physician's treatment orders were implemented.

Inspectors wroteBased on record review and interviews, the facility failed to implement OT (Occupational Therapy) recommendations for one Resident (#77) out of a sample of 33 Residents. Specifically, the facility failed to implement a functional maintenance program after the Resident was discharged from OT.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for two Residents (#3 and #155) out of a total sample of 33 residents. Specifically, 1. For Resident #3, the facility failed to investigate and assess the Resident after sustaining a fall resulting in a left ankle fracture. 2. For Resident #155, the facility failed to attempt to reapply his/her wandergaurd bracelet after multiple days of it not being on the Resident.

Inspectors wroteBased on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for two Residents (#17 and #122) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 33 residents. Specifically, 1. For Resident #17, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow) fistula. 2. For Resident #122, the facility failed to a. ensure nursing staff documented they obtained blood pressures from his/her arm with the AV (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow) fistula and b. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure treatment carts were locked when unattended.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure staff maintained an accurate medical record for three Residents (#77, #146, and #122) out of a sample of 33 residents. Specifically: 1. For Resident #77, the facility inaccurately documented that a left palm guard was applied. 2. For Resident #146, the facility documented that staff unwrapped ace wraps on the Resident's legs on days they did not wrap the Resident's legs. 3. For Resident #122, the facility failed to provide an appropriate and accurate diagnosis for the use of a psychotropic medication.

Inspectors wroteBased on record review and interview, the facility failed to provide the pneumococcal and influenza vaccinations to two Residents (#121 and #4) out of five sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide the COVID-19 vaccination to one Resident (#121) out of five sampled residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued with the required information for three out of three applicable residents reviewed. Specifically, the facility failed to issue the SNF ABN notice, so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. Finding Included: Review of the facility assessment indicated the following: Staffing Plan: -The grid below depicts staffing patterns when a full census of 195 residents. Nursing, however, flex staff based on census and acuity. Weekday average hours per week are as follows: Licensed registered nurses (RN)/licensed practical nurse (LPN): 7:00 A.M.-3:00 P.M.-256 hours, 3:00 P.M.-11:00 P.M.-200 hours, and 11:00 P.M.-7:00 A.M.-176 hours. Certified nursing assistants (CNA: 7:00 A.M.-3:00 P.M.-160 hours, 3:00 P.M. -11:00 P.M.-144 hours, and 11:00 P.M.-7:00 A.M.-64 hours. - Weekend average hours per week are as follows: Licensed registered nurses (RN)/licensed practical nurse (LPN): [...]

Inspectors wroteBased on record review and interviews, the facility failed to obtain informed consent for three Residents, (#155, #84 and #146) out of a total sample of 39 residents. Specifically, 1. For Resident #155, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication. 2. For Resident #84, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication. 3. For Resident #146, the facility failed to obtain a psychotropic medication consent prior to administering a psychotropic medication.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of three nursing units.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a homelike environment on three of four resident care units.

Inspectors wroteBased on record review and interviews, the facility failed to report an altercation between Residents (#68 and #96) and failed to report an allegation of abuse for one Resident (#19) out of a sample of 39 Residents. Specifically, 1. For Residents #68 and #96, the facility failed to report a verbal altercation to the State Agency (SA) within two hours. 2. failed to report an allegation of abuse for one Resident (#19).

Inspectors wroteBased on record review and interviews, the facility failed to investigate an altercation between Residents (#68 and #96) and failed to investigate an allegation of abuse for one Resident (#19) out of a sample of 39 Residents. Specifically, 1. For Residents #68 and #96, the facility failed to investigate a verbal altercation and 2. For Resident 19, the facility failed to investigate an allegation of abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for four Residents (#59, #144, #98, and #103) out of a total sample of 39 Residents. Specifically, the facility failed to: 1. Accurately code the preferred language for Resident #59 2. Accurately code hospice services for Resident #144. 3. Accurately document the presence of a contracture (an abnormal and usually permanent shortening of a muscle, resulting in distortion or deformity; stiffness of the joints that causes deformity and prevents full extension) for Resident #98. 4a. Accurately document the presence of a contracture for Resident #103. 4b. Accurately document the administration of an antipsychotic medication for Resident #103.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure resident centered care plans were implemented and/or developed for seven Residents (#60, #92, #5, #142, #103, #96 and #85) out of a total sample of 39 residents. Specifically, 1. For Resident #60, the facility failed to implement his/her right hand grip splint. 2a. For Resident #92, the facility failed to implement supervision with meals. 2b. For Resident #92, the facility failed to implement booties to his/her bilateral feet while in bed. 3. For Resident #5, the facility failed to implement the plan of care for falls. 4. For Resident #142, the facility failed to develop a plan of care for pain. 5. For Resident #103, the facility failed to develop a plan of care for a contracture. 6. For Resident #96, the facility failed to develop a history of alcohol abuse care plan. 7a. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of nursing practice for four Residents (#107, #101, #142, and #38) out of a sample of 39 residents. Specifically: 1. For Resident #107, (i) The facility failed to regularly notify the Nurse Practitioner after the Resident refused to take his/her prescribed antipsychotic medication. (ii) Notify the Psychiatric Nurse and [NAME] Monitor after the Resident refused to take his/her prescribed antipsychotic medication. 2. For Resident #101, the facility failed to follow the physician's order to contact the medical doctor when a blood sugar value went below the specific levels. 3. For Resident #142, the facility failed to follow physician's orders for an Occupational Therapy (OT) evaluation. 4. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to address the nutrition and hydration status of three Residents (#74, #26 and #38) out of a total sample of 39 residents. Specifically, the facility failed to: 1) address a significant weight change in a timely manner for Resident #74, 2) address a significant weight change in a timely manner and obtain weights for Resident #26 and 3) offer sufficient fluid intake to maintain proper hydration and health for Resident #38.

Inspectors wroteBased on interview, policy review, and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to 1) ensure annual competencies were completed and documented for three out of five certified nursing assistants (CNAs), and three out of four licensed nurses whose education records were reviewed, and 2) ensure licensed nurses received competencies regarding suprapubic catheter care prior to caring for a resident with a suprapubic catheter.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for three of six sampled CNA's.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure medications were stored as required for one Resident (#74), out of a total of 39 sampled residents and ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically: 1. The facility failed to ensure that medication was not left at the bedside for Resident #74 while unsupervised by staff. 2. The facility failed to ensure medications were labeled (date opened) and stored according to manufactures guidelines (refrigerated) on two of four sampled medication carts and two of two sampled medication rooms.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, during observation of the food line in the kitchen, the cook contaminated saran wrap with her chin and chest, then using the contaminated side, applied it over the food on the steam table. Findings Include: On 4/19/24 at 11:20 A.M., Dietary staff #1 pulled saran wrap out of the package, held it in place with her chin and rested it over her apron. The cook then covered a pan of food on the steam table with it contaminated side down. Dietary staff #1 did this a total of four times during preparation of the tray line for the lunch meal. [...]

Inspectors wroteBased on interview and record review the facility failed to offer, or provide education for, the 2023-2024 Covid vaccine for five Residents (#108, #83, #125, #82, and #117) out of a total of five residents reviewed. Findings Include: Review of the facility policy, titled Vaccine Administration, revised September 2022, indicated the following: - The facility must offer residents, visitors, and staff vaccination against COVID-19 when vaccine supplies are available to the facility. -The vaccine may be offered and provided directly by the LTC (long term care) facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that at least 12 hours of in-service training was completed for three of five Certified Nurse Aides (CNAs) reviewed.

Inspectors wroteBased on interviews and observations, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, for residents who were dependent on staff for assistance with meals, staff were standing over the residents while providing assistance, on the third floor unit.

Inspectors wroteBased on observation, record review and interview, the facility failed to notify a resident of a room change, including the reason for the change, for one Resident (#108) out of a total sample of 39 residents. Specifically, the facility failed to provide a written notice explaining the reason for a room change for Resident #108 resulting in the Resident being moved to a new room against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure requests to access personal funds for less than $100.00 ($50.00 for Medicaid residents) were honored within the same day for one Resident (#6), out of 39 total sampled residents. Specifically, the facility required 48 hours notice for a Resident to gain access to $25.00 of personal funds.

Inspectors wroteBased on record review, observation and interviews, the facility staff failed to ensure one Resident (#19) was free from verbal and mental abuse, out of a total of 39 sampled residents. Specifically, Resident #19 was told to wear a bra in a common area by the Administrator and it resulted in mental anguish and psychological distress.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure staff implemented their abuse policy for two Residents (#108, and #19), out of a total sample of 39 residents. Specifically, the facility failed to 1. ensure the accused staff member was not employed in the building while an abuse investigation was still pending for Resident #108 and 2. identify, report, and investigate Resident #19's abuse allegation.

Inspectors wroteBased on record review, policy review, and interview for two Residents (#64 and #118) out of 39 sampled residents, the facility failed to complete a notice of intent to transfer/discharge to the hospital. Specifically, the facility failed to notify the residents in writing for the reason of transfer and send a copy to the ombudsman. Findings Include: Review of the facility policy titled Bed Hold, last revised October 2022, indicated the following but not limited to: Policy: -It is the policy of the facility to provide the resident, responsible party or legal representative with notice of the facilities bed-hold policy upon admission and at the time of transfer or therapeutic leave from the facility to ensure continuity of care and residents post therapeutic leave or hospitalization. Procedure: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#144), who elected to receive hospice care services, out of a total sample of 39 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to revise a care plan for one Resident (#107) out of a sample of 39 Residents. Specifically, the facility failed to update and revise Resident #107's behavior care plan.

Inspectors wroteBased on observations, record review, interviews and policy review the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically, the facility failed to provide assistance with showers, for one Resident (#102), out of a total sample of 39 residents. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, revised October 2022, indicated the following: Policy Statement: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Policy Interpretation and Implementation: -2. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that one Resident (#115) received treatment and care in accordance with professional standards of practice out of a total sample of 39 residents. Specifically, for Resident #115, the facility failed to complete a dressing change in accordance with physician's orders. Findings Include: Resident #115 was admitted to the facility in January 2024 with diagnoses that included dementia, edema, chronic pain, and lack of coordination. Review of Resident #115's most recent annual Minimum Data Set (MDS) Assessment, dated 2/27/24, indicated that he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as having moderate cognitive impairment. On 4/16/24 at 8:01 A.M., the surveyor observed Resident #115 in the dining room. [...]

Inspectors wroteBased on observation, record review and interview for one Resident (#136) the facility failed to implement interventions for the prevention and treatment of pressure ulcers out of a total of 39 sampled Residents. Specifically, for Resident #136 the facility failed to set his/her air mattress to the correct setting.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards. Specifically, the facility failed to: 1) store smoking materials safely for one Resident (#85) and 2) properly investigate and assess a resident after sustaining a fall resulting in hospitalization for one Resident (#74) out of a total sample of 39 residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement trauma informed care plans for two Residents (#155 and # 84) out of a sample of 39 Residents. Specifically, the facility failed to develop a personalized post-traumatic stress disorder (PTSD) care plan for the Residents.

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 one Resident (#40) out of a total sample of 39 Residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices to reduce potential transmission of infection for one Resident (#136), out of 39 sampled Residents. Specifically, for Resident #136, the facility failed to implement enhanced barrier precautions.

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to offer influenza vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#83 and #125) out of a total of five residents reviewed. Findings Include: Review of the facility policy, titled Resident Vaccination revised February 2023, indicated the following: - Residents should be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. - Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. - Provision of such education shall be documented in the resident's medical record. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light system was functioning properly in one Resident's (#38) room on the 5th floor unit.

Inspectors wroteBased on record review and interview, the facility failed to meet the obligation to issue to residents who received services under Medicare Part A, a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), which informs a resident of his/her potential liability for payment and related standard claim appeal rights, for two of three records reviewed.

Inspectors wroteBased on records reviewed and interviews, the facility, which maintained an average daily occupancy of greater than 60 residents (averaging 164 residents per day), failed to ensure the Director of Nurses (DON #1) did not serve as a charge nurse on a unit.

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure they maintained compliance with Federal, State and Local Laws and Professional Standards, as it related to nursing staff working hours in accordance with Massachusetts State General Laws Minimum Nursing Personnel Requirement, when based on the Facility's staffing schedules as-worked and the Timecard Reports for the months of December 2023 and January 2024, Nurse #1 worked 16 or more hours consecutively on a regular basis, and at times, Nurse #1 worked up to 40 hours consecutively.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure they maintained complete and accurate Medical Records when Weekly Skin Evaluations were not consistently documented by nurses for the month of January 2024.

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure that an effective Quality Assurance Program was maintained related to Nursing documentation of Weekly Skin Evaluations.

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3) the Facility failed to ensure they maintained complete and accurate Medical Records when: 1) Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for Resident #1 for the month of 10/2023. 2) CNA ADL documentation was not consistently completed for Resident #2 for the month of 10/2023. 3) CNA ADL documentation was not consistently completed for Resident #3 for the month of 09/2023 and 10/2023, and his/her Weekly Skin Evaluations were not consistently completed by nurses for the months of 09/2023 and 10/2023. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively impaired, the Facility failed to ensure they developed and implemented a Comprehensive Person-Centered Care Plan related to his/her inappropriate behavior of frequently urinating in various places, including common areas, throughout the unit. Findings Include: Review of the Facility Policy titled Care Plan-Comprehensive, dated as revised 10/22/22, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the needs of the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy indicated the Facility utilized electronic health records for resident Care Plans. [...]