Nemasket Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a person-centered comprehensive care plan was developed and/or implemented for one Resident (#31), out of a total sample of 21 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's hearing impairment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#4), out of a total sample of 21 residents. Specifically, the facility failed to implement physician's orders for offloading the Resident's heels while in bed.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Employee Files, (Agency Nurse #1) the Facility failed to ensure they implemented and followed their Abuse Policy when a Criminal Offender Registry Information (CORI) check was not conducted on Agency Nurse #1 prior to her first date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy.

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 05/27/25, after being made aware of an allegation that he/she had been physically abused by a staff member, that they obtained and maintained evidence that a thorough investigation into the allegation had been completed as required, and in accordance with the Facility's Abuse Policy.

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 Three Bay Sink was operated in a safe and sanitary manner to ensure sanitation of the dishes.

Inspectors wroteBased on record review and interview, the facility failed to maintain professional standard of practice for management of bowels for one Resident (#47), out of a total sample of 19 residents. Specifically, the facility failed to ensure hospital discharge orders were implemented, bowel regime was followed per physician's orders, the physician was notified of abnormal stools/bowel sounds/refusal of medications, and skilled notes were written per physician's order.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for one Resident (#67), of one resident receiving dialysis, out of a total sample of 19 residents. Specifically, the facility failed to ensure ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to monitor the nutritional status of two Residents (#41 and #81) with unplanned, significant weight loss, out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #41 to assess for nutritional interventions following a significant weight loss; and 2. For Resident #81, to implement nutritional interventions for a Resident with significant weight loss.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed for two Residents (#50 and #66) to develop and implement comprehensive care plans to reflect the individual needs of the residents, out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #50, to ensure a care plan was developed and implemented to address his/her activity preferences including social, emotional, and spiritual well-being; and 2. For Resident #66, to develop and implement an individualized, resident centered care plan with accommodations for the Resident's blindness in relation to his/her activity pursuits.

Inspectors wroteBased on record review, policy review, observation, and interview, the facility failed to ensure one Resident (#85), out of two residents receiving enteral feedings (intake of nutrients via a tube into the gastrointestinal tract), was administered the prescribed enteral feeding on 2/29/24.

Inspectors wroteBased on policy review, documentation review, observation, and interview, the facility failed to provide one Resident (#66), out of 19 sampled residents, an activity program to assist him/her in meeting their interests, socializing within their community, and supporting their psychosocial well-being while at the facility.

Inspectors wroteBased on policy review, observation, and interview, the facility failed for two Residents (#85 and #13), out of 19 sampled residents, to ensure oxygen tubing and equipment were maintained in a sanitary manner to prevent the potential spread of germs to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a history of trauma and failed to assess for triggers to avoid potential re-traumatization for one Resident (#32) with a history of trauma, out of a total sample of 19 residents.

Inspectors wroteBased on document review, policy review, and interviews, the facility failed to maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility.

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #1), whose physicians orders included the administration of an antidepressant medication daily, the Facility failed to ensure they provided care and services consistent with professional standards of practice, when nursing left Resident #1's medication in a pill cup with him/her, did not stay to observe him/her completely ingest the medications, Resident #1 removed his/her antidepressant from the pill cup, saved up more than a dozen of them, and consumed them in an attempt to end his life. Resident #1 required transfer to the Hospital Emergency Department for evaluation, observation and treatment of an overdose.

Inspectors wroteBased on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #4) whose physician orders included for nursing to conduct 15-minute safety checks, the Facility failed to ensure they maintained complete and accurate medical/clinical records including but not limited to documentation related to the completion of 15-minute safety checks.