Life Care Center of Stoneham

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike setting in resident rooms on the first and second floor nursing units.

Inspectors wroteBased on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were 1. labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, including the expiration date in two of two medication carts and in one vital sign cart observed. 2. were stored in a locked area not accessible to residents and or visitors.

Inspectors wroteBased on observation an interview, the facility failed to implement appropriate monitoring for a pacemaker for one Resident (#25), out of a total of 19 sampled residents.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall and was found on the floor by staff, the facility failed to ensure he/she was free from neglect, when although Resident #1 told staff he/she was hurt and was screaming I'm in pain, without assessing him/her for the potential for injuries, Nurse #1 picked Resident #1 up off the floor put him/her in a wheelchair, picked him/her up again, transferred him/her back into bed and left the room. Despite Certified Nurse Aide (CNA) #1 reporting to Nurse #1 that Resident #1 was still complaining of and was in obvious pain, Nurse #1 did not go check on Resident #1 and still did not assess him/her for injuries. Nurse #1 finished his shift, left the facility and never reported the incident to anyone. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff complaining of pain, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Resident #1 was crying out in pain, without completing any type of assessment, Nurse #1 picked Resident #1 up off the floor, initially put him/her in a wheelchair, then transferred him/her again by picking him/her up out of the wheelchair, put him/her in bed, and left the room. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff and was crying out in pain, the facility failed to ensure he/she was provided with care and treatment consistent with professional standards of practice related to pain management. Certified Nurse Aide (CNA) #1 said she found Resident #1 on the floor in his/her room, he/she was crying out in pain and immediately called Nurse #1 for help. CNA #1 said she asked Nurse #1 more than once to check on Resident #1 that night, because he/she kept crying out in pain. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure professional staff are licensed, certified, or registered in accordance with applicable State laws. Specifically, when the facility indicated they had one nurse employed under a nursing waiver, they failed to ensure that the nurse had graduated from a board approved nursing program. Findings Include: Review of The Department of Public Health (DPH) Circular Letter, issued on June 3, 2024, regarding Guidance for Nursing Practice by Graduates and Students in Their Last Semester of Nursing Education Programs, indicated, but was not limited to: -An individual who graduated from a registered nursing or practical nursing program approved by the board or who is a senior nursing student attending the last semester of a registered nursing or practical nursing program approved by the board may practice nursing; provided that: [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure a dignified existence was maintained for residents who require assistance with meals. Findings Include: Review of facility policy titled Dignity, dated as reviewed 9/25/23, indicated the following: -Each resident has the right to be treated with dignity and respect. -Examples of treating residents with dignity and respect include, but are not limited to: -e. Addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers. On 9/19/24 at 8:03 A.M., the surveyor overheard a staff member in a resident's room yell out into the hallway to another staff member to go downstairs and help with breakfast because they have more feeders on that unit. The Staff member yelling into the hallway was sitting in a resident room, assisting a resident with his/her meal. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a comprehensive person centered care plan for three Residents (#43, #31 and #16) out of a total sample of 20 residents. Specifically, 1. For Resident #43, the facility failed to develop a care plan regarding a new skin tear and treatment applied. 2. For Resident #31, the facility failed to develop a care plan for Resident #31's resident specific Activities of Daily Living needs. 3. For Resident #16, the facility failed to implement the plan of care for completing weekly skin checks.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and hygiene. Specifically, the facility failed to provide nail care for one Resident (#54) out of a total sample of 20 residents. Findings Include: Review of facility policy titled Nail Care. dated as reviewed 9/10/24, indicated but was not limited to the following: - For general fingernail care for most residents, the following procedure will be followed: - 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Resident #54 was admitted to the facility in August 2024 with diagnoses that included fracture of the right femur and muscle weakness. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure standards of quality care were implemented for one Resident (#43) out of a total sample of 20 residents. Specifically, the facility failed to a.) notify the physician or responsible party of a new skin tear, b.) failed to obtain an order for a treatment applied to a new skin tear and c.) failed to document an assessment of the new skin tear.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#31) out of a total sample of 20 residents. Specifically, the facility failed to ensure Resident #31 wore Prevalon boots while in bed, as ordered by the Physician.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure professional standards of practice for food service safety by failing to perform proper hand hygiene.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain an accurate medical record for two Residents (#31 and #43) out of a total sample of 20 residents. Specifically, 1. Nurses documented in the Treatment Administration Record (TAR) that Resident #31 wore Prevalon boots while in bed, contrary to direct observation of the boots not being worn. 2. A nurse inaccurately documented on a Skin Assessment that Resident #43 did not have a skin tear, when he/she had a skin tear to the left hand.

Inspectors wroteBased on records and interviews, for one of three sampled residents (Resident #1) whose Physicians Orders included the administration of multiple bowel medications for the management of constipation and frequently complained of abdominal pain, the Facility failed to ensure they developed and implemented a Comprehensive Plan of Care that identified goals, outcomes and interventions related to constipation and abdominal pain, so identified care needs would be met by Nursing.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of constipation, and had Physician's Order on 07/19/24 and 07/25/24, for Nursing to insert an 18 French Foley Catheter (due to unavailability of a Rectal Tube) into his/her rectum to treat abdominal distention and pain, the Facility failed to ensure nursing staff were competent in the process, which included being aware of Facility Policy and Procedures and documenation requirements.

Inspectors wroteBased on record review, and interview, the facility failed to meet professional standards of care for one Resident (#5), out of a total sample of 21 residents. Specifically: 1. For Resident #5 the facility failed to ensure an occupational therapy assistant provided services within her scope of practice resulting in an injury.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nursing staff implemented orders for one Resident (#5) out of a total sample of 21 residents. Staff failed to remove a leg brace as recommended by the orthopedic surgeon resulting in the worsening of a surgical wound. Subsequently, Resident #5 was hospitalized requiring debridement (a surgical procedure to remove dead tissue) of the wound and sepsis (an infection of the blood stream) with associated Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia requiring a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for IV antibiotics.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that it is free from medication rates of 5% or greater.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened were dated as required and 3. topical and treatment items were not stored with oral medications.

Inspectors wroteBased on observation and interview the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to provide a dignified dining experience for the residents on the first floor unit.

Inspectors wroteBased on record review and interview, the facility failed to honor 1 Resident's (#174) right to refuse treatment out of a total of 21 sampled Residents.

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 two nursing units.

Inspectors wroteBased on observation, interview and policy review, the facility failed to report an allegation of abuse and/or neglect within 2 hours as required for 1 Resident (#324) out of a total sample of 21 residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to 1) investigate an allegation of neglect for 1 Resident (#13) and 2) failed to investigate a bruise of unknown origin for 2 Residents (#6 and #51) out of a total sample of 21 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to implement a skin integrity care plan for 1 Resident (#69) out of a total sample of 21 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with meals as needed for 2 Residents (#6 and #56) out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#51), out of a total sample of 21 residents. The facility failed to ensure Resident #51 was wearing prosthetic device and hand splints.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medical records were accurate for 1 Resident (#25) out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that infection control measures were maintained during medication pass.