Mill Town Health and Rehabilitation

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #3), who required a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with equipment that was specifically designed for and appropriate for safe use during a mechanical lift transfer. On 04/18/26 nursing staff attempted to transfer Resident #3 via mechanical lift using a repositioning device, not a designated lift sling, Resident #3 slid out of the mechanical lift, fell to the floor, hit his/her head and received skin tears as a result of the fall. Resident #3 was transferred to the Hospital Emergency Department and was diagnosed with an Intraparenchymal hemorrhage (brain bleed) as a result of the fall.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure nursing staff promptly notified his/her medical provider and health care proxy of a significant medication error.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 03/29/26, Resident #1 was administered his/her scheduled morning medications, and he/she was also administered Resident #2's medications in error.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who were both severely cognitively impaired, unable to formulate consent and found engaged in touching in a sexual manner, the Facility failed to ensure staff consistently implemented and followed their abuse policy related to reporting abuse allegations, when on 03/04/26 although Certified Nurse Aide #2 immediately reported to Nurse #1 that Resident #2 and Resident #3 were witnessed engaging in sexual behavior, Administration however, was not made aware until on 03/05/26 (the following morning), and failed to ensure their abuse policy aligned with the requirement for allegations of abuse to be reported to their State Agency within two hours.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who were severely cognitively impaired and had been found by staff touching each other is a sexual manner, the Facility failed to ensure staff immediately reported an allegation of resident to resident sexual abuse to Administrative staff as required, so the Facility could report the incident to the State Survey Agency, within the two hour required time frame. On 03/04/26 although a staff member witnessed Resident #2 and Resident #3 engaging in sexual behavior with each other, it was not successfully reported to Administration until the following morning on 03/05/26, (almost 11 hours after the alleged incident occurred) and not reported to their State Agency until 1:29 P.M. that afternoon (more than 18 hours later).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnoses of diabetes with physician's orders related to monitoring his/her blood glucose levels and had been found on the floor after an unwitnessed fall, the Facility failed to ensure he/she was provided with care and services that met professional standards of nursing practice, when nurses 1) failed to recognize signs and symptoms of hypoglycemia (low blood sugar) and assess and treat him/her per physician's orders, and 2) failed to adequately assess and provide first aid for a potential burn, after being observed to have a reddened area after having been found down and lying up against a baseboard heater.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record when nursing staff failed to document neurological signs following an unwitnessed fall.

Inspectors wroteBased on record review and interview the facility failed to ensure behavioral health services, related to Substance Use Disorder (SUD), were provided to one Resident (#70) out of a total sample of 22 residents. Specifically, the facility failed to follow up with Resident #70 as indicated by providing psychiatric talk therapy; and, during the time behavioral health services failed to follow up with Resident #70, after he/she used an illicit substance (cocaine) which required hospitalization. Findings Include: Review of the facility policy titled, Treatment Options for Residents with Substance Use Disorder, dated 11/4/24, indicated The facility will offer appropriate and individualized treatment for all residents living with the disease of addiction or with a history of substance use disorder. [...]

Inspectors wroteBased on record review, and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for six Residents (#14, #36, #65, #5, #29 and #62), out of 22 sampled residents. Specifically: 1. For Resident #14 the facility failed to ensure the MDS assessment was accurately coded for skin conditions (section M). 2. For Resident #36 the facility failed to ensure the MDS assessment was accurately coded for the use of restraints. 3. For Residents #65, #5 and #29, the facility failed to ensure the MDS assessment was accurately coded related to pneumococcal vaccination status. 4. For Resident #62, the facility failed to ensure the MDS assessment was accurately coded for a resident who had been discharged .

Inspectors wroteBased on observations, interviews, and record review, the facility to ensure that services provided met professional standards for five Residents (#11, #36, #2, #21, #28), out of 22 total sampled residents. Specifically, 1. For Resident #11, the facility failed ensure that the air mattress was functioning. 2. For Residents #36, #2, #21, #28 the facility failed to ensure weekly skin checks were completed as indicated in the physician's orders. 3. For Resident #28, the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission and at the initiation of an antipsychotic medication.

Inspectors wroteBased on observation, record review and interviews, the facility failed to review and implement wound physician treatment recommendations for one Resident (#14) out of a total sample of 22 residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure that medications were dated once opened, according to manufacturer's guidelines. Further, the facility failed to ensure that medications with shortened expiration dates were removed from the medication cart when expired and were not available for administration in one of two medication carts observed. 2. The facility failed to ensure treatment carts were locked while a nurse was not present on both the second and third floor units. 3. The facility failed to ensure nursing staff kept the medication cart clean and organized in one of one medication cart observed on the second-floor unit. 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer Pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#65, #29 and #5), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on record review and interviews, the facility failed to report a potential allegation of abuse for one Resident (#7) out of a total sample of 22 residents.

Inspectors wroteBased on record review and interviews, the facility failed to fully investigate a potential allegation of neglect for one Resident (#7) out of a total sample of 22 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Living was provided for two Residents (#27 and #11) out of a total sample of 22 residents. Specifically: 1. For Resident #27 the facility failed to ensure supervision and cueing with meals was provided. 2. For Resident #11 the facility failed to ensure supervision with meals was provided.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement safe smoking for one Resident (#70), out of two sampled residents who smoked cigarettes. Specifically for Resident #70, the facility failed to ensure a smoking assessment was completed and a plan of care was developed prior to the Resident smoking at the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that services were provided in accordance with professional standards for two Residents (#17 and #2) with a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition) out of two applicable residents, out of a total sample of 22 residents. Specifically, 1) For Resident #17 the facility failed to ensure tube feeding water flushes (intermittent boluses of water, stored in a separate bag, automatically dispensed during regular intervals in conjunction with enteral nutrition formula for purpose of hydration and maintenance of tube patency) was running at the correct setting as indicated in the physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Residents (#71), out of one Resident with a PICC Line. Specifically, for Resident #71, the facility failed to ensure that when the PICC line dressing was lifting (compromised), it was changed, and that the insertion site was able to be visualized.

Inspectors wroteBased on record review and interviews, the facility failed to assess and provide treatment for pain for one Resident (#7) with a diagnosis of acute pain due to trauma out of a total sample of 22 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide medically related social services to one Resident (#70) who had an active diagnosis of Substance Use Disorder (SUD) (out of a total sample of 22 residents. Specifically, the facility failed to ensure the Social Worker implemented SUD interventions prior to Resident #70's hospitalization for his/her drug use and failed to re-assess after the Resident was re-admitted and confirmed to have actively use an illicit substance (cocaine).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide follow-up dental services and obtain dentures for one Resident (#21), out of a total sample of 22 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to 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. Specifically, for Resident #14, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, colostomy, and IR drain (a drainage procedure performed by Interventional Radiology). Findings Include: Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for three Residents (#65, #11 and #6), out of a total sample of 22 residents.

Inspectors wroteBased on observations, records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), the Facility failed to ensure they developed and implemented an individualized comprehensive plans of care that included interventions, treatment goals, and measurable outcomes, when 1) for Resident #2, his/her Plan of Care did not include his/her transfer status for the need of two staff member assistance with a mechanical Lift, and did not include interventions for him/her to be transferred out of bed daily, and 2) for Resident #3, his/her plan of care did not include his/her preference to be barefoot.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had a physician's order for nursing to document every shift on his/her transfers in and out of bed, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing documentation was inconsistent, with many days not even one progress note was written by nursing.

Inspectors wroteBased on record review, policy review and interview the facility failed to notify the physician of a significant change in status for five Residents (#48, #79, #58, #9 and #60) out of a total sample of 26 residents. Specifically: -The facility failed to notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters, or when insulin was held due to hypoglycemia.

Inspectors wroteBased on record review, policy review and interview for 5 residents (#48, #79, #58, #9 and #60) out of a total sample of 26 residents, the facility failed to ensure it administered insulin to residents diagnosed with diabetes, according to physician orders and facility policy. Specifically: 1. The facility failed to follow physician orders for when to give or hold insulin based on blood glucose levels. 2. The facility failed to follow its policy and procedures for hypoglycemia and hyperglycemia.

Inspectors wroteBased on record review, policy review, staff education record review, Facility Assessment review, and interviews, the facility failed to ensure that the three out of thirteen nurses (Nurse #5, #6, and #10) completed annual training and competencies related to the provision of care and services for five insulin dependent Residents (#48, #79, #58, #9, and #60) out of a total sample of 26 Residents. Specifically, the facility failed to: 1. Notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters, or when insulin was held due to hypoglycemia. 2. Follow physician orders for when to give or hold insulin based on blood glucose levels. Findings Include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; [...]

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. Specifically, the facility failed to ensure food was labeled, and that dented cans of food were not stored with usable cans.

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 (#74 and #81) out of a sample of 26 Residents. Findings Include: Review of the facility policy titled Psychoactive Drug Monitoring, revised June 2022, indicated the following: -All psychoactive medication requires consent for use from the resident or legally responsible party prior to administration of medication. 1. Resident #74 was admitted to the facility in March 2024 with a diagnosis of manic depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/24/24, indicated that Resident #74 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating the Resident had moderate cognitive impairment. [...]

Inspectors wroteBased on record review, policy review and interview the facility failed to ensure a plan of care was developed and implemented, with safeguards to prevent further potential abuse, following an allegation of rape was made by one Resident (#70) out of a total sample of 26 residents. Specifically, Resident #70 reported an allegation of rape by a family member, was sent to the hospital for a rape kit assessment and returned to the facility. The investigation into this allegation is ongoing by the District Attorney's office, and since the allegation was made on 4/26/24 the facility failed to develop a plan to protect the resident or other residents of the facility in the event that the alleged perpetrator came to the facility to visit Resident #70.

Inspectors wroteBased on observation, record review and interview the facility failed to implement the plan of care for two Residents (#15 and #13) out of a total sample of 26 residents. Specifically: 1. For Resident #15 the facility failed to ensure built up utensils and a nosey cup were provided with meals as indicated in the plan of care. 2. For Resident #13 the facility failed to a.) ensure his/her bed was maintained in the low position as indicated in the plan of care and b.) complete weekly skin assessments as ordered by the physician.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure supervision and assistance for Activities of Daily Living (ADLs) was provided to three Residents (#15, #13 and #14) out of a total sample of 26 residents. Specifically: 1. For Resident #15 the facility failed to ensure continual supervision, and assist as needed, was provided with meals. 2. For Resident #13 the facility failed to ensure supervision and assistance with meals was provided. 3. For Resident #14 the facility failed to provide assistance with showers.

Inspectors wroteBased on record review, interview and observation, the facility failed for 1 (Resident #5) of 26 sampled residents to set the air mattress pressure to the correct, physician-ordered setting. Specifically, the physician order indicated the air mattress should be set to 100 pounds (lbs.) and for three days the pressure was set to 400 lbs.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#74) out of a total sample of 26 residents. Specifically, the facility failed to implement an intervention intended to prevent further falls after Resident #74 sustained a fall.

Inspectors wroteBased on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for three Residents (#70, #24 and #26) who have a history of trauma out of a total sample of 26 residents. Specifically: 1. For Resident #70, the facility failed to develop a trauma care plan, with individualized triggers and interventions, following an allegation of rape made by Resident #70 and failed to complete a PTSD assessment quarterly and following the allegation of rape. 2. For Resident #24, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. 3. For Resident #26, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#81) out of a total sample of 26 Residents. Findings Include: Review of facility policy titled Drug Regimen Review, dated as effective 6/2022, indicated: -The consultant Pharmacist reviews the medication regimen of each active resident at least monthly. Findings and recommendations are reported to the Director of Nursing and the Medical Director. -3. The consultant Pharmacist documents potential or actual medication therapy problem and communicate them to the responsible prescriber, unit manager and the Director of Nursing (DON) and the Medical Director. [sic] -4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide rehabilitation services for one Resident (#53) out of a total sample of 26 residents. Specifically, the facility failed to evaluate a Resident's hand after a hand splint in place for limited range of motion was discontinued due to Resident refusals, and after the Nurse Practitioner documented that she was concerned about Resident #53's nails digging into his/her palm due to a possible hand contracture.

Inspectors wroteBased on records reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#35) out of a sample of 26 residents. Specifically, for Resident #35 nursing documented they obtained blood pressure from his/her right arm when they did not.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs.

Inspectors wroteBased on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program.

Inspectors wroteBased on record review and interview, the facility failed to specifically: 1) Develop a care plan for dementia and vision for two Residents (#16 and #30), 2) Failed to implement the plan of care as ordered for three Residents (#69, #63 and #37) out of a total sampled 39 residents.

Inspectors wroteBased on observations, record reviews, policy review and interviews, the facility specifically: 1) Failed to prevent an elopement of one Resident (#80) from the facility and ensure a wander guard was in place after the elopement, 2) Failed to provide the correct diet for one Resident (#89) who had a recent choking episode, and 3) Failed to complete investigations and fall assessments after three Residents (#45, #80 and #16) falls, out of a total sample of 39 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to provide a dignified dining experience to 1) the residents on the second floor unit and 2) Resident #22, out of a total sample of 39 residents.

Inspectors wroteBased on record review and interview, the facility failed to obtain updated informed consent for antipsychotic and psychotropic medications for two Residents (#4 and #16) out of a total sample of 39 residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to ensure a call light was within reach for two Residents (#72 and #22) out of a total sample of 39 residents.

Inspectors wroteBased on interview and record review, the facility failed to file a grievance for one Resident (#40) out of a total sample of 39 residents.

Inspectors wroteBased on observations, record reviews, policy review and interviews, the facility failed to keep one Resident (#69) free from restraints while eating in the dining room, out of a total sample of 39 residents.

Inspectors wroteBased on observations, record reviews, policy reviews and interviews, the facility failed to investigate bruises of unknown origin for two Residents (#7 and #4) out of a total sample of 39 residents.

Inspectors wroteBased on record review and interview, the facility staff failed to ensure that services provided meet professional standards of quality, for one Resident (#57) out of a total sample of 39 residents.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to specifically; provide needed assistance for activities of daily living for one Residents (#63) out of a total sample of 39 residents.

Inspectors wroteBased on observation, record review and interviews, the facility specifically: 1) Failed to obtain a physician order for the use of oxygen for two Residents (#35 and #12), 2) Failed to ensure an oxygen filter was cleaned for one Resident (#4) out of a total sample of 39 Residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure services consistent with professional standards were provided for one Resident (#64) who required dialysis (a procedure to remove waste products and excess fluids from the body when the kidneys fail to properly work), out of a total sample of 39 residents. The facility failed to ensure that Resident #64's post dialysis weights were documented as ordered.

Inspectors wroteBased on record review and interview, the facility failed to obtain appropriate consent for an antipsychotic medication for one Resident (#60), resulting in the Resident receiving the medication for four months without consent, out of a total sample of 39 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication was re-evaluated and included a duration of use for one Resident (#67) out of a total sample of 39 residents.

Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of three nurses observed made 3 errors in 29 opportunities on two of two units resulting in a medication error rate of 10.34%. These errors impacted two Residents (#24 and #21), out of four residents observed.

Inspectors wroteBased on observations, policy review and interviews the facility failed: 1, To ensure medications with shortened expiration dates were labeled and dated after being opened in 2 out of 2 medication carts, and in one medication room. 2, To ensure orally administered medications are kept separate from externally used medications.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for one Resident (#69) out of a total sample of 39 Residents

Inspectors wroteBased on interview and observations, the facility failed to disinfect shared resident medical equipment and adhere to infection control during medication pass.