Medway Country Manor Skilled Nursing & Rehabilitat

Inspectors wroteBased on interview and record review, the facility failed to provide adequate pain management for one Resident (#7), out of a total sample of 24 residents, when the facility was unable to reach the Resident's primary care physician for a prescription to order Resident's Oxycodone (short-acting opioid medication used to treat moderate to severe pain), resulting in the Resident suffering with severe pain of 7 on a scale of 1-10 with 10 being the worst pain for 19 hours post-admission.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, the facility failed to ensure their grievance policy included the right to file grievances anonymously and failed to ensure residents were aware of and had access to formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment on two out of three units. Specifically, the facility failed to ensure: 1. For the [NAME] unit, the residents' environment was free of a pervasive pungent odor of feces and urine; and 2. For one room on the second floor, the footboard was in place.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure for three Residents (#105, #106, #29), out of a total sample of 24 residents, that services were provided to maintain their vision or hearing abilities. Specifically, the facility failed:1. For Residents #105 and #106, to ensure they were provided with audiology services after the Residents notified staff that their hearing aid devices were not working properly/broken, to support the Residents' hearing needs; and2. For Resident #29, to arrange for an optometry appointment to address the Resident's vision impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure a nebulizer machine (used to treat airway obstruction and bronchospasm by nebulizing aerosol medications) mouthpiece and reservoir (chamber that hold the liquid medication) were maintained in a sanitary manner for one Resident (#106), of 24 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete an assessment with the Preadmission Screening and Resident Review Level I (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to document the resident's diagnosis of Post-traumatic stress disorder (PTSD) in Question 4A, history of substance use disorder (SUD) in Question 4B and Department of Mental Health (DMH) Involvement/case management in Question 5A resulting in an incorrect negative serious mental illness (SMI) screen.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a person-centered plan of care which included care and management for one Resident (#15) who had been determined by the staff to be at risk of elopement (an incident when a resident leaves the premises or a safe area without authorization or the necessary supervision to do so safely), out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nutritional status was maintained for two Residents (#83 and #3), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #83, to ensure a strict fluid restriction was provided and accurately documented.2. For Resident #3, to ensure a strict fluid restriction was provided and accurately documented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with professional standards of practice. Specifically, the facility failed to ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside for one Resident (#126), out of a total sample of 24 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 01/18/25, after being notified of an allegation of verbal abuse by staff, the Activity's Director did not immediately report the allegation of verbal abuse to Administration, and did not do so until two days later.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that on 01/20/25, after Facility Administration was made aware of an allegation of verbal abuse of a resident (Resident #1)by a staff member (Certified Nurse Aide #1), that they reported the allegation to the Department of Public Health (DPH) within two hours as required, when it was not reported to DPH until 01/23/25, (three days later).

Inspectors wroteBased on observations, records reviewed and interviews, for three of seven sampled residents (Resident #3, Resident #5, Resident #6), who required transmission based precautions to be utilized by nursing staff during the provision of care, the Facility failed to ensure, 1) that nursing staff were competent and had the necessary skill set to appropriately care for residents by donning the correct Personal Protective Equipment (PPE) when a resident was on Contact Precautions (CP) or Enhanced Barrier Precautions (EBP), when nursing staff members were observed not following precautions while caring for these residents and 2) that after a nursing staff member responsible for providing direct care to residents tested positive for Group A streptococcal Infection, (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive [...]

Inspectors wroteBased on records reviewed and interviews for one of seven sampled residents (Resident #1), who per Laboratory test results reported to the facility on 1/19/25 indicated he/she tested positive for Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions), the Facility failed to ensure Nursing promptly notified the physician of the results, who was not informed until four days later (1/22/25), as a result Contact Precautions were not initiated timely, therefore placing other residents and staff at risk for potentially contracting and spreading the infectious disease.

Inspectors wroteBased on records reviewed and interviews, for two of three nursing units (West and Second) after a staff member Certified Nurse Aide (CNA) #1 tested positive for Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions) on 1/18/25, facility administration failed to ensure it provided appropriate administrative oversight of Infection Control Practices when CNA #1 was not removed from the schedule until being on antibiotic therapy for 24 hours. [...]

Inspectors wroteBased on observations, records reviewed and interviews for five of seven sampled residents (Resident #1, Resident #2, Resident #3, Resident #5 and Resident #6), all of which required the need for staff to use Personal Protective Equipment (PPE) during the provision of care due to an active infection, the Facility failed to ensure they implemented and maintained an infection control program that helped prevent the development and spread of infections, including Group A Streptococcal (GAS, a bacterium that can cause many different infections, including strep throat and also cause severe, life-threatening invasive disease, spread person to person through respiratory droplets or direct contact with an infected person's skin sores, nose, throat or wound secretions), that required treatment with antibiotics, when 1) 1/19/25 laboratory results for a resident who tested positive for GAS was not [...]

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to ensure nursing staff were able to demonstrate the appropriate competencies and skill sets for 4 out of 5 licensed nurses and for 4 out of 5 Certified Nursing Assistants (CNAs). Specifically, the facility failed to ensure: 1. Staff were able to identify and distribute modified diet textures to residents, as ordered; and 2. Licensed nurses (Nurse #4, #6, #9, and Unit Manager #1) and CNAs (#1, #3, #5 and #6) had demonstrated competency in skills necessary to care for residents.

Inspectors wroteBased on employee record review and interview, the facility failed to complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 out of 3 CNA employee records reviewed.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required 12 hours (no less than) of annual training, which at a minimum must include dementia and abuse training for 3 out of 3 CNA education files reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure three Residents (#78, #66, and #43), in a sample of 22 residents, had been seen by a physician every every 60 days and that required visits alternated between the Physician and the Nurse Practitioner (NP). Specifically, the facility failed to ensure for: 1. Resident #78, required visits alternating between the Physician and the NP occurred every 60 days; and 2. Resident #66, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days; and 3. Resident #43, required visits alternated between the Physician and the NP occurred every 30 days for the first 90 days then every 60 days.

Inspectors wroteBased on observation, record review, interviews, and review of the facility assessment, the facility failed to provide sufficient support personnel with appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, the facility failed to: 1. Ensure support staff with appropriate competencies and skills were available to provide meals that meet the residents' needs; and, 2. Provide documentation that dietary competencies were conducted on all dietary personnel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate modified texture diet was prepared and served for one test tray. Additionally, the facility failed to ensure food was prepared and served in a form designed to meet the individual needs of five Residents (#98, #353, #67, #39, and #19), out of a total of 22 sampled residents. Specifically, the facility failed: 1. To prepare and serve a test tray with a ground-textured diet; 2. For Residents #98 and #353, to prepare and serve a ground diet per the physician's order; and 3. For Residents #67, #39, and #19, to prepare and serve a chopped diet per the physician's orders.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen was maintained in a sanitary and safe condition.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that pneumonia vaccines were administered to 12 Residents (#29, #53, #8, #54, #24, #85, #91, #17, #79, #19, #353, #63) with signed consents (by the resident or Health Care Proxy) to receive the vaccine, of a total sample of 20 residents reviewed for immunizations. Specifically, a random sample of 20 residents who consented to receive the pneumonia vaccine was reviewed. Of the 20 residents who gave consent to receive the pneumonia vaccine, 12 residents had not been given the pneumonia vaccine as of 11/25/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#15), out of 22 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address Resident #15's pain.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#42) of 22 sampled residents, the facility failed to ensure a resident was provided care in accordance with professional standards of practice. Specifically, for Resident #42, the facility failed to accurately transcribe his/her orders for levofloxacin (antibiotic) resulting in 14 additional doses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure wound treatments were conducted for one Resident (#353), in a total sample of 22 residents. Specifically, for Resident #353, the facility failed to perform treatments to two wounds on the right foot, per physician's orders.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#66) of 22 sampled residents, the facility failed to ensure that pain management was provided to the Resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences. Specifically, the facility failed to implement recommendations made by the consulting physiatrist (medical doctor who specializes in physical medicine and rehabilitation who diagnose the cause of the pain and aid in developing a comprehensive treatment plan).

Inspectors wroteBased on observation, record review, and interviews, the facility failed for one Resident (#48), out of a total sample of 22 residents, to ensure professional standards of care and treatment for hemodialysis (a treatment where a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body). Specifically, the facility failed to have a person-centered care plan with individualized interventions, failed to monitor and care for the access site, and failed to ensure communication including labs, changes in condition, medications, and advanced directives between the facility and dialysis treatment center was ongoing and collaborative.

Inspectors wroteBased on interview and record review, the facility failed to assess and eliminate triggers for a Resident (#99) with a history of trauma, to avoid potential re-traumatization, out of a total sample of 22 residents.

Inspectors wroteBased on document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) reports for two Residents (#51 and #68), out of a total sample of 22 residents, were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Consultant Pharmacist.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#42) of 22 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility failed to ensure Resident #42's levofloxacin (antibiotic) was administered for only three doses as ordered by the physician, resulting in an additional 14 administrations.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#51) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 22 residents. Specifically, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made three errors out of 27 opportunities, totaling a medication error rate of 11.11%. These errors impacted two Residents (#97, #256), out of five residents observed. Specifically, 1. For Resident #97, Nurse #3 omitted medications and did not notify the provider; and 2. For Resident #256, Nurse #3 administered a normal saline flush to his/her intravenous device (a catheter inserted into a blood vessel) without an order.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles of practice. Specifically, the facility failed to: 1. Store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the key; and 2. Provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the handrail in the corridor of the [NAME] Unit was secured to the wall for one of three resident units.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was diagnosed with dementia, had an activated Health Care Proxy, and had physicians orders for the administration of psychotropic medications, the Facility failed to ensure Resident #1's Health Care Agent and/or alternates were provided with necessary information including the risks and benefits of psychotropic medications and failed to ensure they obtained written informed consent for their use, prior to administration of an antidepressant and antipsychotic medication.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), after facility staff were made aware on 05/06/24 by a Family Member of an allegation that he/she was sexually abused by a staff member, the Facility failed to ensure staff implemented and followed their abuse policy when 1) Certified Nurse Aide (CNA) #1 and CNA #2 (who fit the description of the accused staff member) were not immediately suspended pending an investigation, and 2) failed to conduct Massachusetts Nurse Aide Registry (NAR) check and Criminal Offender Record Information (CORI) checks prior to CNA #1 and CNA #2's date of employment at the Facility, in accordance with their Abuse Policy. Both of these issues placed their resident's at risk for potential abuse.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that after an administrative staff member (Director of Nurses) was made aware on 05/06/24 of an allegation of sexual abuse, that it was reported to the Department of Public Health (DPH) within two hours as required, when it was not reported to the DPH until 05/07/24, the following day.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was a long-term care resident without any discharge plans, the Facility failed to permit Resident #1 to return following a hospitalization on 11/09/23, and despite an Appeal Decision on 12/01/23 in favor of Resident #1 which ordered the Facility to rescind the Notice of Intention Not to Readmit Following Hospitalization, the Facility refused to permit Resident #1's return and Resident #1 remained hospitalized for more that 60 days while the hospital sought alternate placement.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure that concerns addressed by the Resident Council Group had sufficient follow-up to address and prevent recurrence. Specifically, the facility failed to initiate a late medication administration grievance after the residents brought up the concern in the June 2023 and July 2023 Resident Council meetings.

Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to follow the plan of care for treatment and prevention of a pressure ulcer for three Residents (#75, #88, and #64), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #75, who has multiple stage 4 pressure ulcers (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) and a Deep Tissue Injury (DTI- pressure related injury to subcutaneous tissue under intact skin), to ensure the air mattress was at the correct setting; 2. For Resident #88, to obtain a physician's order for an air mattress, including appropriate settings, monitoring and checking for function and placement; and 3. [...]

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 3 out of 4 nurses observed made 4 errors out of 28 opportunities, resulting in a medication error rate of 14.29%. Those errors impacted 3 Residents (#28, #46, and #19), out of 4 residents observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate documentation in the medical record for three Residents (#84, #18, and #64), out of a total sample of 28 residents. Specifically: 1. For Resident #84, the nurses documented in the Treatment Administration Record (TAR) that safety mats were in place, when they were not; 2. For Resident #18, the facility failed to ensure nursing maintained an accurate order for two physician's orders of sennosides (medication used to treat constipation) which did not contain a dosage as required; and 3. For Resident #64, the physician's ordered Ferrous Sulfate (medication used for anemia) did not contain a dosage as required.

Inspectors wroteBased on record reviews, policy review, and staff interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccines (help prevent pneumococcal disease) for two Residents (#88 and #17), out of a total sample of five residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to identify and assess the use of locking a wheelchair and placing mobile residents at the table as a potential restraint for one Resident (#58), out of a total sample of 28 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#60), of a total sample of 28 residents. Specifically, the facility failed to ensure Unit Manager #1 reported an allegation of potential abuse to the Administrator as required.

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify and complete a Significant Change in Status Minimum Data Set assessment (MDS) assessment for one Resident (#18), who elected to receive hospice care services, out of a total sample of 28 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to develop and implement an effective person-centered baseline care plan within 48 hours of admission to the facility for one Resident (#342), out of a total sample of 28 residents. Specifically, the facility failed to develop a baseline care plan including interventions pertaining to falls for a Resident assessed to be at a high risk for falling; the Resident subsequently fell.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to develop and implement care plans for two Residents (#36 and #14), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #36, to develop and implement a Suicidal Ideation (SI) care plan following a hospitalization for SI; and 2. For Resident #14, a dialysis patient, to develop and implement an individualized dialysis care plan.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the care plan for one Resident (#84) was reviewed and revised by an interdisciplinary team to include new interventions ordered by the physician, out of a total sample of 28 residents. Specifically, the facility failed to revise the care plan to include a physician's order for safety fall mats.

Inspectors wroteBased on record review and interviews, the facility failed to follow professional standards of practice for two Residents (#84 and #14), out of a total sample of 28 residents. Specifically: 1. For Resident #84, the nurses documented on the Treatment Administration Record (TAR) that safety mats were in place beside the bed, as ordered by the physician, when they were not; and 2. For Resident #14, the facility failed to check the Resident's vitals and blood pressure before administering Metoprolol (a medication used to treat high blood pressure).

Inspectors wroteBased on record review, interview, policy review, and observation, the facility failed to ensure physician-ordered hearing aids were provided to two Residents (#88 and #18), out of a total sample of 28 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and maintenance of an indwelling catheter (a flexible tube that inserted through the urethra and into the bladder to drain urine) consistent with professional standards of practice, for two Residents (#88 and #64), out of 28 sampled residents. Specifically, the facility failed: 1. For Resident #88, to assess for and obtain physician's orders for the use of and care/management of an indwelling urinary catheter, and the potential of removal of the catheter; and 2. For Resident #64, to follow the physician's order for the maintenance of a urinary drainage bag.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to properly manage the enteral tube feeding for one Resident (#11), out of a total sample of 28 residents.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#343), out of a total sample of 28 residents. Specifically, for Resident #343, the facility failed to obtain measurements and obtain physician's orders for dressing changes and flushes, as required.

Inspectors wroteBased on observation, policy review, record review, and interviews, the facility failed to ensure nursing provided respiratory care consistent with professional standards of practice for two Residents (#87 and #24), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #87, who required tracheostomy care and tracheal suctioning, to ensure nursing obtained physician's orders for tracheostomy care and tracheal suctioning; and 2. For Resident #24, to ensure nursing changed oxygen tubing, and provided the correct concentration of Oxygen as ordered.

Inspectors wroteBased on record review and interviews, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one Resident (#14), of five receiving dialysis services, out of a sample of 28 residents. Specifically, the facility failed to document weights and vitals in a dialysis communication book pre-dialysis and failed to receive communication from the dialysis center with weights and vitals post-dialysis.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to implement a trauma informed care plan for one Resident (#36), out of a sample of 28 residents. Specifically, the facility failed to develop a Post-Traumatic Stress Disorder (PTSD) care plan for Resident #36 who has an active diagnosis of PTSD.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure two Nurses (#2 and #3) were competent and had the required skill set to prepare and administer the correct dose of Diclofenac Sodium External Gel (topical pain medication) impacting two Residents (#28 and #46).

Inspectors wroteBased on records reviewed, policy review, and interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications are limited to 14 days unless the prescribing practitioner documents a rational to extend the medication for one Resident (#18), in a total sample of 28 residents. Specifically, for Resident #18 the facility failed to ensure as needed Klonopin (psychotropic medication) had a stop date as required.

Inspectors wroteBased on observation, interview and policy review the facility failed to: 1. Properly lock medication carts and a medication storage room, and 2. Ensure medications were securely stored at the bedside for one Resident (#19), out of total sample of 28 residents. Specifically, Resident #19's Solanpas (medicated pain patches) patches were on the bedside table, unattended.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to a) store food, and b) handle food, in accordance with professional standards for food service safety.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure the facility developed a hospice plan of care as required for one Resident (#18), out of a total sample of 28 residents.