Kimwell Nursing and Rehabilitation

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had a homelike environment on three of three units. Specifically, the facility failed to: 1. Repair water damaged ceiling tiles on the K3 unit; 2. Ensure Resident #18 had a bedroom with walls, blinds, and durable medical condition in good repair; and 3. Ensure residents' bedrooms were homelike and free from holes and damaged window treatments on the K1 and K2 units.

Inspectors wroteBased on interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified. Specifically, the facility failed to ensure timely and accurate surveillance data for all infection types to identify a pattern of E-Coli Urinary Tract Infections (UTI) (bacterial infection, caused by E-Coli bacteria, typically originating from the gut, entering the urinary tract, and causing inflammation, often due to improper wiping/perineal care) and implement interventions to decrease the risk of residents developing E-Coli UTIs.

Inspectors wroteBased on interview and document review, the facility failed to implement an antibiotic stewardship program which included a system to monitor antibiotic use, including prophylactic antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance. Specifically, the facility failed:1. For Resident #56, to document the rationale for antibiotic treatment of an infection not meeting the criteria of an infection;2. For Resident #2, to ensure he/she was prescribed an antibiotic susceptible to the organism growth and to document rationale for antibiotic treatment of an infection not meeting the criteria of an infection;3. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure activities of daily living (ADL) care was provided to maintain good personal hygiene for one Resident (#35), in a total sample of 21 residents. Specifically, the facility failed to ensure showers were offered and provided per his/her shower schedule.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident at with an alteration in skin integrity related to a wound, specifically chronic venous ulcers, received necessary treatment and services to promote healing for one Resident (#74), out of a total sample of 21 residents. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary for seven days.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Properly monitor medication refrigeration temperatures in one of three medication storage rooms reviewed to ensure the safety and integrity of vaccines stored; and2. Provide a permanently affixed compartment and separate from all other medications for the storage of schedule IV (low potential for misuse and dependence) controlled substance in two of three medication room refrigerators reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for two Residents (#74 and #35), out of a total sample of 21 residents. Specifically, the facility failed to ensure:1. For Resident #74, the Medical Orders for Life Saving Treatment (MOLST) in the Electronic Medical Record (EMR) matched the active Do Not Resuscitate, Intubate, or Ventilate physician's order; and2. For Resident #35, with a diagnosis of dysphagia (difficulty swallowing), he/she did not have conflicting therapeutic diet orders of Regular texture versus Mechanical Soft/Ground texture in the active medical record.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who became unsteady during a transfer and was lowered to the floor by staff, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 08/30/25, after Resident #1 was lowered to the floor, two Certified Nurse Aides (CNAs) transferred him/her up off the floor without informing and having the nurse assess him/her first for the potential for physical injury, Resident #1 exhibited a sudden change in his/her condition, with signs and symptoms of severe pain, was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fracture of his/her left hip.

Inspectors wroteBased on observations, interviews, and maintenance record review, the facility failed to ensure the environment was free from accident hazards for two out of three units in the facility. Specifically, the facility failed to ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms and shower rooms.

Inspectors wroteBased on interview and record review, the facility failed to provide the Pneumococcal and Influenza immunizations as requested/consented for three Residents (#94, #90 and #11), out of a total sample of five residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Court Order of Appointment of Guardian for an Incapacitated Person was followed for one Resident (#77), in a sample of 20 residents. Specifically, the facility failed to ensure for Resident #77 that the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, which was signed by the previous Health Care Proxy (HCP), was voided with the appointment of a court designated guardian (a professional guardian who is unrelated to the incapacitated adult) who revoked the previous HCP and did not have authority to make advanced directive treatment decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#2) with a diagnosed mental condition, out of a total sample of 20 residents.

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow professional standards of practice to administer oxygen therapy as ordered for one Resident (#68), in a total sample of 20 residents. Specifically, the facility administered Oxygen at 5 liters (L) per minute for Resident #68 with an order for Oxygen at 2L.

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on four days for the period of 7/1/24 to 9/30/24.

Inspectors wroteBased on record review and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#77), in a total sample of 20 residents. Specifically, the facility failed to obtain a social history for Resident #77 which included complicated family relations, possible lack of care in the community from a family member, and a history of substance use disorder.

Inspectors wroteBased on the Beneficiary Protection Notification Review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) to two of three sampled Residents (#207 and #208) and failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two of three sampled Residents (#208 and #86).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when on 09/05/24, Resident #1 was found sitting on the floor against the bed after an unwitnessed fall.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was found sitting on the floor against his/her bed after an unwitnessed fall, the Facility failed to ensure they maintained complete and accurate medical/clinical records, when there was no nursing documentation in the Medical Record related to Resident #1's unwitnessed fall. Finding Include: Review of the Facility Policy titled, Charting and Documentation, dated as revised July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record. The Policy further indicated that the following information is to be documented in the resident medical record: -objective observations; -treatments or services performed; [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) met the needs of each resident. Specifically, the facility failed to: a. Ensure medication kits were replaced by the pharmacy after being opened with medications removed, and not accounted for; b. Ensure proper handling of extra unused medications; and c. Ensure prescriptions for controlled substances were logged into the narcotic register.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that all medications and biologicals were labeled in accordance with currently accepted principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, the facility failed to label medication stored in the medication storage room.

Inspectors wroteBased on interview and review of training documentation, the facility failed to ensure 5 out of 5 sampled employees were provided training on prevention of abuse, neglect, exploitation, misappropriation of resident property, and dementia management.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for two Residents (#36, #22), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #36, to ensure three of the physician prescribed morning medications were not continuously scheduled to conflict with the Resident's scheduled dialysis treatment, when the Resident was known to be out of the facility; and 2. For Resident #22, to ensure the nurse administered medication following the facility's policy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to one dependent Resident (#14), out of a total sample of 23 residents. Specifically, the facility failed to provide assistance with grooming and supervision while eating.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure there was adequate supervision and assistance during smoking sessions for two Residents (#1 and #32), and the resident designated smoking area complied with the Centers for Medicare and Medicaid Services (CMS) guidance for a safe smoking area. Specifically, the facility failed to: 1. Provide adequate supervision for Resident #1 and #32 when attempting to ignite and extinguish their cigarettes; and 2. Provide all smoking residents with a dignified smoking experience, including protection from the elements and have readily available safety equipment in the designated smoking area.