Odd Fellows Home of Massachusetts

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist three Residents (#30, #62, and #88), with signed consents, out of a total sample of 19 residents, in obtaining routine dental care, increasing the Residents' risks for unidentified dental disease and deteriorating oral health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement infection control practices to prevent transmission of infections for three Residents (#64, #13, and #32), out of a total sample size of 19 residents. Specifically, the facility failed:1. For Resident #64, to implement Contact precautions (the use of protective equipment such as gowns and gloves to prevent the spread of parasites from one person to another) in accordance with Resident's plan of care plan increasing the risk to other residents, staff and visitors for contracting scabies (tiny mites that burrow under a person's skin, lay eggs and trigger an allergic reaction that causes itching). 2. For Resident #13, to implement Contact Precautions when the Resident became symptomatic and tested positive for Clostridioides difficile (C. diff: [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain a clean and homelike environment for two Residents (#52 and #70), out of a total sample of 19 residents, on one unit (Second Floor-South) out of five units observed. Specifically, the facility staff failed to ensure that: -Resident #52's bedroom floor was maintained in a clean and sanitary manner. -Resident #70's bed frame, bed rail, mattress, floor mat and bedroom floor were maintained in a clean and sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate vision care services for one Resident (#62), out of a total sample of 19 residents, increasing the Resident's risk for further deterioration of vision when the Resident, who was diagnosed with diabetes and hypertension, had bilateral cataracts and left eye blindness. Specifically, for Resident #62, the facility failed to schedule vision care appointments and ensure that the Resident was seen and received appropriate treatment to maintain vision abilities, when the Resident consented to and requested vision care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#88), out a total sample of 19 residents. Specifically, for Resident #88, the facility failed to obtain a physician's order for a baseline oxygen flow rate, oxygen titration liter flow range, and portable oxygen flow rate when the Resident was diagnosed with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen use placing the Resident at risk for respiratory complications related to oxygen use.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal immunization to one Resident (#119), out of five applicable residents reviewed for pneumococcal immunization in a total sample size of 19 residents. Specifically, the facility staff failed to offer pneumococcal immunization to Resident #119 who was at high risk for pneumococcal infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior pneumococcal immunizations in his/her medical record, and pneumococcal immunization had not been identified as medically contraindicated.

Inspectors wroteBased on interview and record review, the facility failed to offer COVID-19 immunization to one Resident (#119), out of five applicable residents reviewed for COVID-19 vaccination in a total sample size of 19 residents. Specifically, the facility staff failed to offer COVID-19 immunization to Resident #119 who was at high risk for COVID-19 infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior 2025-2026 COVID-19 variant immunizations in his/her medical record, and COVID-19 vaccinations had not been identified as being medically contraindicated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide and environment as free of accident hazards as possible for three Residents (#83, #35, and #53) out of a total sample of 18 residents. Specifically, facility failed to: 1. implement safe swallow strategies for Resident #83 when the Resident had a history of swallowing difficulty, oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing), Dementia, and had an overall decline in function requiring dependence on staff for eating, which increased the Resident's risk for choking and/or aspiration (when food or liquids enters one's airway or lungs). 2. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide routine dental services for one Resident (#46), out of a total sample of 18 residents. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #46 received routine dental services as requested, resulting in complications related to dental deterioration for the Resident.

Inspectors wroteBased on observation, and interview, the facility failed to provide a clean and homelike environment for one Resident (#35) out of a total sample of 18 residents. Specifically, the facility failed to provide Resident #35 with a wheelchair that was maintained in a clean manner and address promptly any cleaning needs as required.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete a Level I PASRR for one Resident (#83) out of a total sample of 18 residents, which resulted in the Resident not receiving a Level II PASRR Evaluation to determine whether the Resident met criteria for serious mental illness (SMI) and whether specialized services were required to treat the Resident's SMI. Specifically, the facility failed to: -Identify Resident #83's diagnosis of Schizophrenia on the Resident's Level I PASRR when the Resident had a diagnosis of Schizophrenia. -Indicate legal involvement within two years prior to admission to the facility when the Resident had a legal guardian appointed through the court system within two years prior to admission to the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide services that met professional standards of quality for two Residents (#83 and #37) out of a total sample of 18 residents. Specifically, the facility failed to: 1. assess Resident #83's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP) when the Resident had experienced a decline in swallowing function and weight loss, and required a diet texture downgrade, resulting in a delayed treatment for the Resident. 2. ensure Resident #37 had the correct Physician ordered size indwelling urinary catheter (a soft flexible tube that drains urine from the bladder) in place, placing the Resident at risk for complications related to the urinary catheter.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that one Resident (#46) out of a total sample of 18 residents with contractures received services and treatment to increase range of motion and/or prevent further decrease in range of motion. Specifically, the facility failed to timely assess, monitor and/or treat Resident #46's right third and fourth finger mild contractures.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#46, #69, and #83), out of a total sample of 18 residents. Specifically, the facility failed to: 1. accurately document measurements of urinary output as ordered when Resident #46 was identified as having a urinary catheter drainage system that provided numerical output measurements. 2. accurately document 24-hour fluid intake and urinary output (I & O) for Resident #69 when the Physician ordered 24-hour I & O monitoring to be completed and documented by staff. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#69) out of a total sample of 18 residents. Specifically, for Resident #69, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment, for one Resident (#49) out of a total sample of 18 residents. Specifically, the facility failed to assess the side rails and mattress in active use for entrapment when Resident #49 had limited mobility and utilized bilateral side rails, placing the Resident at risk for possible entrapment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN- notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for three Residents (#17, #35 and #38), out of three applicable residents, so that the Residents could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Specifically, the facility failed to issue a SNF ABN: 1. For Resident #17, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Medical Director attended two out of the four quarterly QAPI meetings as required.

Inspectors wroteBased on records reviewed, review of surveillance camera video footage and interviews, for one of three sampled residents (Resident #1) who had moderate cognitive impairment, history of behaviors and was dependent on staff for care, the Facility failed to ensure he/she was free from physical and verbal abuse when on 12/06/23/23, during the day shift, Certified Nurse Aide (CNA) #1 was seen on video footage pulling Resident #1 backward out of the elevator, then he hit/slapped him/her on the left side of the back of his/her head/neck/face area, and can then be seen standing over him/her engaging verbally and physically as he moves his arms/hands in front of Resident #1's face. The altercation between Resident #1 and CNA #1 was witnessed by another resident and other staff members, who said CNA #1 was antagonizing and threatening Resident #1 and that he/she was visibly upset by the incident.

Inspectors wroteBased on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1) who was physically abused by a staff member, the Facility failed to ensure they reported a reasonable suspicion of a crime, when although the Administrator was aware on 12/06/23, that Certified Nurse Aide (CNA) #1 hit Resident #1 in the head/neck/face area, and substantiated the incident as physical abuse, the Facility did not notify local law enforcement until 12/20/23, the day of survey.

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 after being made aware on 12/06/23 of an allegation of physical and verbal abuse, that they obtained and maintained evidence that a thorough investigation was completed.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the Resident's/Resident Representative's (RRs) choices for one Resident (#27), out of a total sample of 19 residents. Specifically, the facility failed to adequately assess Resident #27's acute change in condition and accurately monitor his/her food intake or fluid intake and fluid output when the Resident demonstrated frequent refusal of medications, had reduced food and fluid intake, had a history of constipation, and complained of abdominal pain, which resulted in rectal fecal impaction and hospitalization.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to provide necessary nutrition and hydration treatment, services, assessment and monitoring for one Resident (#27) out of a total sample of 19 residents. Specifically, the facility failed to: Provide necessary treatment and services to promote food and fluid consumption, and accurately monitor food and fluid intake for Resident #27 when the Resident was identified as having potential nutrition and swallowing problems. The facility also failed to assess and manage changes in the Resident's functional status pertaining to eating and drinking and an unidentified rectal fecal impaction (inability to evacuate large hard stool, most commonly found in the rectum), and provide required assistance from facility staff to eat and drink.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that four Residents (#37, #42, #9 and #57) out of total sample of 19 residents, were afforded a dignified dining experience. Specifically, the facility staff failed to be seated next to the Residents while assisting them during meals on one (Unit Two) of two units observed.

Inspectors wroteBased on observations, interviews, and policies reviewed, the facility failed to provide a sanitary and homelike environment during dining on one of two resident units. Specifically, the facility staff failed to: -ensure that residents were served meals at the same time for residents seated at the same table. -ensure meals were served off of meal trays. -ensure that staff conducted hand hygiene while providing meals and between assisting residents with meals. -ensure that staff were seated while assisting residents with meals in the Unit Two Dining Room.

Inspectors wroteBased on record review and interview, the facility failed to obtain a completed Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form for one Resident (#239) out of a total sample of 19 residents. Specifically, the facility staff failed to have Resident #239, and/or their Resident Representative date as required, a completed MOLST form.

Inspectors wroteBased on observations, interviews, and policies reviewed, the facility failed to prevent and reduce the potential spread of infection by maintaining an effective infection surveillance program. Specifically, the facility failed to ensure that: 1. residents with active respiratory symptoms were identified and interventions put in place to reduce the spread of infection to other residents. 2. staff were conducting hand hygiene as indicated during resident care activities, including meals and a wound treatment for Resident # 48.

Inspectors wroteBased on records reviewed and interviews, the facility failed to develop, review, and revise comprehensive care plans with the interdisciplinary team (IDT) and include the participation of the Residents/Resident Representatives (RRs) for two Residents (#27 and #14), out of a total sample of 19 residents. Specifically, the facility failed to: 1. Develop and review Resident #27's comprehensive care plan with the Resident and/or RR's participation when the RR was available for participation. 2. Notify Resident #14 and his/her RR of a scheduled interdisciplinary care plan meeting that was held to review the Resident's comprehensive care plan, resulting in the care plan review occurring without the Resident and/or his/her Representative participation.

Inspectors wroteBased on observations, interviews, records and policy review, the facility failed to ensure that two Residents (#51 and #54) out of a total sample of 19 residents, were provided timely activities of daily living (ADLs - Daily self-care activities like grooming, eating, dressing) assistance. Specifically, the facility staff failed to ensure: 1. For Resident #54, that timely assistance during meals and personal hygiene relative to nail care were provided. 2. For Resident #51, that timely assistance during meals and grooming assistance relative to facial hair were provided.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to provide two residents (#12 and #54) with an environment as free of accident hazards as possible. Specifically, the facility failed to: 1. Implement effective fall prevention interventions for Resident #12, to reduce the risk for fall related injuries when the Resident was identified as having a seizure disorder, abnormal gait, and a history of falling, and sustained frequent falls resulting in striking his/her head and sustaining upper extremity bruising and skin tears. 2. Ensure supervision was provided to minimize accidents/hazards related to falls, drinking fluids not ordered by the Physician, and potential resident to resident interactions for Resident #54.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#33), out of 2 applicable residents who receive dialysis (removal of toxins from the blood in people whose kidneys stop working properly), out of a total sample of 19 residents, received care and services relative to dialysis services. Specifically, the facility staff failed to ensure that Resident #33 received breakfast as required and medications as ordered by the Physician on scheduled dialysis days.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#4 and #99), out of five applicable residents, out of 32 opportunities. Specifically, the medication error rate was observed to be 6.5% when: 1. For Resident #4, relative to the administration of eye drops not given as ordered. 2. For Resident #99, relative to the total dose of Potassium Chloride medications not given as ordered by the Practitioner.