Melrose Healthcare

Inspectors wroteBased on observations and interviews, the facility failed to ensure a dignified dining experience on one out of two units. Specifically, on the second-floor unit, residents were served their meals on Styrofoam takeout containers, in Styrofoam cups, and with plastic utensils.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a safe environment on two of two units. Specifically, the facility failed to maintain safe water temperatures in resident bathrooms.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that resident food was dated and not kept past the printed expiration dated in two of two unit refrigerators.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement the plan of care for one Resident (#35), out of a total sample of 23 residents. Specifically, the facility failed to incorporate the use of recommended front anti-tippers (used to prevent a person from tipping a wheelchair over) for the Resident's wheelchair.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#98), 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 23 Residents. Specifically, for Resident #98, the facility failed to implement an order for an air mattress at the settings indicated in the physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to develop a person-centered Post-Traumatic Stress Disorder (PTSD) care plan for two Residents (#3 and #6), out of a sample of 23 residents. Specifically, the facility failed to identify potential triggers in order to eliminate or mitigate situations that may cause re-traumatization of the Resident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that medications were accurately implemented by nursing for one Resident (#11), out of a total sample of 23 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to accurately implement a Gradual Dose Reduction on an antipsychotic medication as recommended by Behavioral Health Services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dental services were provided for one Resident (#43), out of a total sample of 23 residents. Specifically, the facility failed to facilitate the implementation of the dentist's recommendation for new dentures.

Inspectors wroteBased on record review and interview, the facility failed to ensure the 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 accurately documented in the medical record for one Resident (#98), out of a total sample of 23 residents. Specifically, for Resident #98, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently and accurately documented in the medical record.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Residents (#15 and #98), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #15, to implement contact precautions; and 2. For Resident #98, to ensure that the urinary catheter drainage bag was not placed directly on the floor.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to implement multiple wound care treatment recommendations as recommended by the consultant Wound Physician Assistant (PA), including not implementing the recommended treatment type and/or at the recommended frequency, resulting in the deterioration of pressure ulcers and development of bilateral heel osteomyelitis (an infection of the bone).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a dignified dining experience for the residents of the facility as well as provide a dignified existence for four Residents (# 52, #14, #57 and #13), out of a total sample of 23 residents. Specifically, the facility failed to: 1) provide a dignified dining experience to the residents on the first and second floor, 2) provide privacy during care for Resident #52, 3) provide dignity while providing incontinence care by using double incontinence briefs for Residents #52, #14 and #57 and 4) provide a dignified environment for Resident #13.

Inspectors wroteBased on observation and interview, the facility failed to maintain a home-like environment. Specifically, 1. The facility failed to ensure that the second floor was free from odors. 2. For Resident #80, the facility failed to ensure the resident's room did not smell of urine and was free from small black flying insects. 3. For Resident #52, the facility failed to ensure his/her mattress was intact without any missing fabric.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#20, #14, #88) out of a total sample of 23 residents. Specifically, 1. For Resident #20, the facility failed to develop a comprehensive pacemaker care plan. 2. For Resident #14, who was assessed to be at moderate risk for falls the facility failed to implement non-skid strips by his/her bed as per the plan of care. 3. For Resident #88, the facility failed to develop a personalized care plan with resident-specific interventions for suicidal indication history. 4. For Resident #88, the facility failed to develop and implement a personalized care plan for use of a hand orthotic as indicated by Occupational Therapy

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician orders were implemented for two Residents (#70 and #4) out of a total sample of 23 residents. Specifically, 1. For Residents #70, who is at risk for developing pressure ulcers, the facility failed to ensure his/her air mattress was set according to the physician's order. 2. For Resident #4, the facility failed to follow a physician's order to obtain a Urine Analysis in a timely manner.

Inspectors wrote2c. Resident #34 was admitted to the facility in February 2024 with diagnoses including hemiplegia. Review of Resident #34's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored 13 out of a possible 15 on the Brief Interview for Mental Status (MDS) which indicated he/she is cognitively intact. The MDS also indicated Resident #34 required partial to moderate assistance for self-feeding tasks. On 4/6/25 at 8:14 A.M., Resident #34 was observed lying in bed while eating breakfast. There were no staff in the room to provide assistance if needed and the Resident was not visible from the hallway. On 4/6/25 at 12:45 P.M., Resident #34 was observed eating lunch at a table at the end of the second-floor unit hallway. There were no staff at that end of the hallway and the Resident was not visible from the nursing station. [...]

Inspectors wroteBased on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: Review of the facility assessment, reviewed 3/5/25, indicated: Direct Care Staffing Ratios: Unit A: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs. Unit B: Days 3 CNAs, Evenings 3 CNAs, Nights 2 CNAs. 2nd Floor: Days 4 CNAs, Evenings 4 CNAs, Nights 3 CNAs. Review of this facility assessment indicated total CNA staffing required for facility from 3/5/25 to 4/9/25 should be: Days 10 CNAs, Evenings 10 CNAs, Nights 7 CNAs. [...]

Inspectors wroteBased on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.

Inspectors wroteBased on personnel file review and interview, the facility failed to ensure annual performance reviews were completed at least every 12 months for 5 of 5 Certified Nurse Aides (CNAs) personnel files reviewed.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure a medication cart, treatment carts on the first and second floor and the second floor's medication room were locked while a nurse was not present.

Inspectors wroteBased on observation, record review and interview, the facility failed to serve what was listed on the menu for all meals during the survey period. Specifically, the facility failed to ensure residents received milk with their meals as indicated on the menu.

Inspectors wroteBased on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units.

Inspectors wroteBased on observation and interview the facility failed to properly follow food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consent for the use of psychotropic medication for one Resident (#8) out of a total sample of 23 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Roger's treatment plan (a judge and legal guardian decide when an antipsychotic medication can be administered) was valid and kept up to date for one Resident (#8) out of a total of 23 sampled Residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to file a grievance for one Resident (#80), out of 23 total sampled residents. Specifically, the facility failed to ensure staff filed a grievance on behalf of Resident #80, who complained that his/her pants were missing.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#20, and #9), out of a total sample of 23 residents. Specifically, 1. For Resident #20, the facility failed to ensure his/her pacemaker checks were completed. 2. For Resident #9, the failed ensure six bilateral foot wounds were assessed and measured weekly.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards for two Residents (#149 and #88) out of a total sample of 23 residents. Specifically: 1. For Resident #149, the facility failed to implement fall interventions after a fall. 2. For Resident #88, the facility failed to ensure that the Resident was wearing a smoking apron as indicated in the medical record while the Resident was smoking.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#12) out of a total sample of 23 residents. Specifically, the facility failed to a. obtain weekly weights to monitor the weight for Resident #12 as ordered and b. provide the dietary supplements as indicated by the Registered Dietitian.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice two Residents (#92, and #13) out of a total sample of 23 residents. Specifically: 1. For Resident #92, the facility failed to ensure oxygen was set to the level prescribed by the physician and maintain a clean filter on the oxygen concentrator; and 2. For Resident #13, the facility failed to ensure oxygen was set to the level prescribed by the physician.

Inspectors wroteBased on record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#13) 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 23 residents. Specifically, for Resident #13, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV fistula (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow. This term is interchangeably used with AV shunt.).

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care was developed for Trauma-Informed Care for two Residents (#57 and #88), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 23 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident (#8) was free from unnecessary psychotropic medications, out of a total sample of 23 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow the recommendations of the dentist to ensure a referral was made to the oral surgeon for one Resident (#92) out of a total sample of 23 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for two Residents (#12, #4) out of a total sample of 23 Residents. Specifically: 1. For Resident #12, the facility failed to ensure the Resident was receiving Nectar Thickened Liquids as ordered. 2. For Resident #4, the facility failed to ensure that the Resident was receiving a Dysphagia Mechanical Soft diet and Nectar Thick Liquids as ordered.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to document presence of six bilateral foot wounds in weekly skin evaluations.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #9, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents on 3 of 3 units had access to the use of a telephone where calls can be made without being overheard.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for two Residents (#47, and #53) out of a total sample of 20 Residents. Specifically the facility failed to; 1.) develop a vision, communication and fall risk care plan for Resident #47, 2.) develop a pacemaker care plan for Resident #53.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to properly secure medications and medication carts on two of four units. 2. The facility failed to ensure medications were labeled and stored according to manufacturer's guidelines in two of four medication carts.

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

Inspectors wroteBased on record review and interviews, the facility failed to obtain consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#47 and #76) out of a sample of 20 Residents.

Inspectors wroteBased on record review and interview the facility failed to ensure advanced directives related to guardianships were valid and in place for two Residents, (#16 and #12) out of a total of 20 sampled Residents. Specifically: 1.) For Resident #16, the facility failed to ensure an established Guardianship was reviewed and renewed annually per court order, and; 2.) For Resident #12, the facility failed to establish a health care agent/representative when his/her activated health care proxy was no longer reachable or involved in his/her care.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from involuntary seclusion, out of a total sample of 20 Residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from restraints out of a total sample of 20 residents. Specifically, the facility failed to identify and assess the use of a pillow under a fitted sheet as a potential restraint for Resident #31.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility to ensure that services provided met professional standards for one Resident (#13), out of 20 total sampled Residents. Specifically, the facility failed to implement a daily wound dressing according to the physician's order for five days.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide assistance with meals for two Residents (#379 and #30) out of a total sample of 20 residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide an activity program for three Residents (#31, #38 and #47) out of a total sample of 20 residents.

Inspectors wroteBased on record review an interview, the facility failed to follow up on a referral for ophthalmology services for one Resident (#12) out of a total of 20 sampled Residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#4) out of a sample of 20 residents. Specifically for Resident #4, the facility to ensure oxygen was administered in accordance with the physician's orders. Findings Include: Review of facility policy titled Oxygen Administration, revised January 2024, indicated to review the physician's orders for oxygen administration and to evaluate oxygen saturation. Resident #4 was admitted to the facility in March 2018 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and weakness. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services consistent with professional standards of practice related to hemodialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for one Resident (#65) out of a total sample of 20 residents. Specifically, for Resident #65 the facility failed to ensure: 1. That a plan of care was developed for his/her AV (aterio-venous) Fistula (dialysis access site). 2. That emergency supplies were at the bedside in accordance with the physician's orders. Findings Include: Review of facility policy titled Hemodialysis Access Care, revised November 2017, indicated: [...]

Inspectors wroteBased on Record review and interviews the facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for one Resident (#76) out of a sample of 20 residents.

Inspectors wroteBased on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for one Resident (#76) out of a total sample of 20 residents. Specifically, for Resident #76 the facility failed to ensure a 14 day stop date for a PRN Ativan (a psychotropic medication used to treat anxiety) order. Findings Include: Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation. Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired. Review of Resident #76's physician's orders, dated 3/19/24, indicated: Ativan 0.5 milligrams every four hours as needed. [...]

Inspectors wroteBased on observations, record reviews, policy review and interviews, the facility failed to maintain accurate medical records for three Residents (#31, #13, and #76) out of a total sample of 20 Residents. Specifically: 1) For Resident #31, the facility inaccurately documented the Resident had been transferred out of bed. 2) For Resident #13, the facility documented a daily wound dressing as completed, when it was not completed according to the physician's order for five days; and 3) For Resident #76 the facility failed to accurately document skin assessments on the weekly skin evaluation.