North End Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for two of three residents (Resident #89 and #23) observed to receive medication during the survey. This resulted in a facility medication error rate of 28%.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed for one Resident (#69), out of 20 sampled residents, to provide standards of quality nursing practice related to diabetes mellitus management. Specifically, for Resident #69 the nursing facility staff failed to obtain and record Resident #69's blood sugar in accordance with the physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed for one Resident (#10), out of a total sample of 20 residents to provide quality standards of nursing care. Specifically, the facility staff failed to identify a large discoloration consistent with a bruise on Resident #10's right forehead.

Inspectors wroteBased on observations, records review and interview the facility failed to ensure for one Resident (#46) out of total sample of 20 residents, was provided professional standards of care. Specifically, the facility failed to implement having Resident #46's suprapubic catheter changed in accordance with the urology medical plan.

Inspectors wroteBased on record review and interview, the facility failed to immediately perform cardiopulmonary resuscitation (CPR) according to professional standards of care for one Resident (#89), who was a full code, out of a total sample of 26 residents. Specifically, after Resident #89 was found with no pulse the nurse on duty, whose CPR certification had expired, left the Resident in a room with a Certified Nursing Aide (CNA), while he retrieved life saving materials and called 911, delaying life saving CPR measures for Resident #89.

Inspectors wroteBased on record review and interview, the facility failed to ensure the assigned nurse was competent to perform Cardiopulmonary Resuscitation (CPR) on one Resident (#89), who was a full code, after he/she was found unresponsive, out of a total sample of 26 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nursing staff adhered to professional standards of practice for the administration of free water flushes and enteral tube feeding (water and nutrition taken through a tube directly into the stomach) for six out of seven Residents (#18, #40, #67, #71, #72 and #73) with a tube feed observed. Specifically: 1. For Resident #18, the facility failed to label and date the enteral free water administration bag. 2. For Resident #40, the facility failed to label and date the water administration bag and failed to ensure the amount of tube feeding administered followed the physician's order. 3. For Resident #67, the facility failed to label the tube feeding bottle and the free water administration bag with the date and time hung. 4. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a comprehensive resident-centered care plan was developed for two Residents (#5 and #33) out of a total sample of 26 Residents. Specifically, 1. For Resident #5, the facility failed to identify the make, model, serial number, cardiologist information, implant date, and pacer rate for the monitoring and care of a pacemaker. 2. For Resident #33, the facility failed to develop an individualized comprehensive resident-centered care plan related to the monitoring and care of a pacemaker.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided the necessary care and services in accordance with professional standards of practice for two Residents (#47 and #71), out of a total sample of six residents on a ventilator.

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 and treatment carts on the fourth floor were locked while a nurse was not present.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate medical record for two Residents (#71 and #72), out of a total sample of 26 residents. Specifically: 1. For Resident #71, the facility documented the ventilator tubing was changed when it was not. 2. For Resident #72, the facility documented the Resident recieved tube feedings at the wrong time. 1. Resident #71 was admitted to the facility in January 2025 with diagnoses including protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #71 was severely cognitively impaired, as evidenced by a score of 7 out of 15 on the Brief Interview for Mental Stats exam. Further review indicated that Resident #71 was substantially/dependent on staff for all activities of daily living. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement adverse event monitoring to potentially prevent future adverse events from occurring. Specifically, one Resident (#89), who was a full code, was found unresponsive and expired and the facility failed to identify and investigate the death, as it relates to Quality Assurance and Performance Improvement (QAPI).

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to identify and assess the use of pillows underneath a fitted sheet, bilaterally, as a potential restraint for one Resident (#63) out of a total sample of 19 residents. Findings Include: Review of facility policy titled Use of Restraints, dated as revised April 2017, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -1. Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -6. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement care plans for one Resident (#57) out of a total of 19 sampled residents. Specifically, the facility failed to develop and implement a plan of care related to an implantable cardioverter defibrillator.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to meet professional standards of nursing practice for two Residents ( #18 and #3) out of a total sample of 19 Residents. Specifically, 1. For Resident #18, the facility failed to failed to address suicide threats in a timely manner. 2. For Resident #3 the facility failed to follow the recommendations from a physiatrist (a doctor who specializes in physical medicine and rehabilitation) for physical therapy and occupational therapy evaluations.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain accurate medical records for one Resident (#41) out of a total sample of 19 residents. Specifically, the facility inaccurately documented the changing and replacement of a suprapubic catheter. Findings Include: Resident #41 was admitted to the facility in March 2022 with diagnoses that include muscle wasting and atrophy, benign prostate hyperplasia and retention of urine. Review of Resident #41's most recent Minimum Data Set (MDS) Assessment, dated 5/1/24, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating that the Resident has severe cognitive impairment. The MDS further indicated the presence of an indwelling urinary catheter. On 5/23/24 at 6:46 A.M., the surveyor observed a urinary drainage bag hanging on Resident #41's bed frame. [...]