Life Care Center of Leominster

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, and was found with new areas of bruising on his/her left upper arm, the Facility failed to ensure that Resident #1 and other residents on his/her unit were protected from potential further abuse by a staff member, when on 04/07/26, although the Assistant Director of Nurses (ADON) was aware that Resident #1 had alleged that staff were rough with him/her during care, the Facility failed to ensure they conducted a thorough investigation into his/her bruising of unknown origin. The Facility's Report did not include an investigation into Resident #1's allegation of rough handling as potential for abuse and they did not obtain and maintain copies of witness statements, therefore placing residents at risk for the potential abuse.

Inspectors wroteBased on record review, and interview, the facility failed to implement their policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the pneumococcal immunization for four Residents out of five sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain kitchen equipment in safe operating condition. Specifically, the facility failed to ensure the walk-in freezer door was functioning properly resulting in ice build-up on the freezer floor and frost covering food product inside the freezer.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one Resident (#104) was assessed for and free from restraints out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #104 was free from a restraint in the form of pillows being stuffed under his/her fitted sheets to keep the Resident in bed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#50) out of a total sample of 25 residents. Specifically, the facility failed to date and initial a bandage on Resident #50's left lower extremity.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide respiratory care services consistent with professional standards of practice for one Resident (#26) out of a total sample of 25 residents. Specifically, the facility failed to develop and maintain a plan for the care of the nebulizer machine, (a small machine that turns liquid medicine into a mist that can be easily inhaled), mask and tubing.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a current hospice plan of care was present in the medical record and coordinated with facility staff for one Resident (#11) out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an environment that was free from physical restraints for one Resident (#56) out of a total sample of 23 residents. Specifically, the facility failed to assess and re-evaluate the need for physical restraints with the use of Resident #56's bed positioned flush against the wall on the left side of the bed that restricted the Resident from exiting the left side of the bed if needed.

Inspectors wroteBased on interview, observation, record and policy review, the facility failed to ensure that one Resident (#60) of four applicable residents, out of a total sample of 23 residents, received care and services for his/her pressure ulcer (a wound, usually over a bony prominence, that is caused by unrelieved pressure to the area) in accordance with professional standards of practice. Specifically, the facility failed to ensure a wound dressing was in place as ordered by the Physician, placing the Resident at risk for infection and worsening of his/her pressure ulcer.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon as required for two Residents (#60 and #79), of five applicable residents reviewed for unnecessary medications, out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. For Resident #60, ensure that MRR recommendations for discontinuation of an antihistamine medication and an acetylcholinerase inhibitor medication were reviewed by the Physician and responded to as required. 2. For Resident #79, ensure that MRR recommendations for medication administration changes of a mild pain reliever, a NMDA receptor antagonist, an anti-seizure medication and discontinuation of a probiotic and multivitamin medication were reviewed by the Physician and responded to as required.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the medication regimen was free from unnecessary medication for one Resident (#60), of five applicable residents reviewed for unnecessary medication review, out of a total sample of 23 residents. Specifically, the facility failed to ensure Resident #60 was free from administration of an excessive duration for an antibiotic eye ointment medication that was ordered by the Physician for a duration of seven days and was administered to the Resident for a duration of ten days.

Inspectors wroteBased on record and policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations for one Resident (#24), of five applicable residents, out of a total sample of 23 residents. Specifically, the facility failed to offer Resident #24 an updated COVID-19 vaccination when medical record documentation indicated that he/she was eligible.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff conducted testing for staff, to prevent the spread of infection, when the facility was experiencing an outbreak of COVID-19. Specifically, the facility staff failed to conduct outbreak testing for three (CNA#1, Other Staff#1, and Nurse #3) out of three sampled staff as soon as possible, when a COVID-19 positive resident was identified in the facility, and every 48 hours thereafter as required.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff accurately completed Minimum Data Set (MDS) assessments for three Residents (#43, #77, and #252), out of 18 sampled residents. Specifically, the facility failed to ensure its staff accurately coded MDS assessments to: 1.) reflect the presence of an unhealed pressure ulcer (PU: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff implemented positioning interventions for two Residents (#43 and #49), as indicated in their care plans, out of 18 sampled residents. Specifically, the facility failed to ensure its staff 1.) provided assistance to Resident #43 for repositioning at least every two hours when the Resident required repositioning at that frequency and was unable to reposition him/herself, and to minimize pressure over bony prominences, as indicated in the care plan and 2.) provided positioning devices for Resident #49 required to assist in healing and preventing pressure injuries (PIs), as indicated in the Resident's care plan.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure its staff developed interventions following a fall with a major injury, for one Resident (#71), out of 18 sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff offered a therapeutic diet for one Resident (#43), out of 18 sampled residents. Specifically, the facility failed to ensure its staff offered the Resident his/her breakfast meal when the Resident was identified as at risk for dehydration and malnutrition and required a therapeutic diet.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that its staff provided care consistent with professional standards of practice related to the care and services of dialysis (a procedure to remove waste products and excess fluid from the body when kidneys stop working properly) for one Resident (#252), out of two sampled residents, in a total of 18 sampled residents. Specifically, the facility failed to communicate effectively with the dialysis provider by sending Resident #252 to the dialysis clinic without pertinent clinical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff maintained accurate medical records for two Residents (#15 and #77), out of 18 sampled residents. Specifically, the facility failed to ensure its staff maintained medical records to reflect accurate documentation relative to: 1.) the election for use of short-term artificial hydration for Resident #15 and 2.) the election for no use of non-invasive ventilation for Resident #77 when the Resident was using continuous positive airway pressure (CPAP: machine that uses mild air pressure to keep breathing airways open while one sleeps).

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure that its staff implemented appropriate infection control practices related to the use of Personal Protective Equipment (PPE) and hand hygiene during wound care provided to one Resident (#252), out of 18 sampled residents.