Pioneer Valley Living and Rehab

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #8, #32, and #35) reviewed. The facility reported a census of 48 residents.

Inspectors wroteThe facility failed to properly complete the Centers of Medicare & Medicaid form #10055 for 3 of 3 sampled residents. (Residents #4, #8 and #54). The facility reported a census of 48 residents. Findings Include: 1. The ABN form #10055 dated 1/26/26 for Resident #4 revealed the form lacked the reason Medicare may not pay and the estimated cost of services. 2. The ABN form #10055 dated 8/5/25 for Resident #8 revealed the form lacked the estimated cost of skilled nursing care. 3. The ABN form #10055 dated 10/2/25 for Resident #54 revealed the form lacked the estimated cost of skilled nursing care. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASARR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 out of 2 residents (Resident #14) reviewed for PASARR requirements. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to revise and update care plans to include hospice care for 1 out of 12 residents reviewed (Resident #6). The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to notify the physician after resident refused ordered daily weights or were not completed for 1 of 1 residents reviewed (Resident #6) for daily weights. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview the facility failed to complete skin assessments, notify the physician in a timely manner regarding a new pressure area to the coccyx area to ensure resident received necessary treatments, interventions and supplements to properly prevent a stage 2 pressure ulcer consistent with professional standards of practice for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 48 residents.

Inspectors wroteBased on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review, the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 45 residents.

Inspectors wroteBased on observations, interviews, and facility policy the facility failed to provide dignity to 1of 5 residents reviewed (Resident #6). The facility failed to provide dignity to the resident as demonstrated by the resident waiting to return to her room from the dining room while sitting in soiled garments. The facility reported a census of 45 residents. Findings Include: The Minimum Data Set (MDS) in progress for Resident #6, dated 3/31/25, identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognitive functioning. The resident had diagnoses of hemiplegia or hemiparesis (stroke with an affected extremity(ies)), depression, and muscular dystrophy, unspecified. [...]

Inspectors wroteBased on facility record review and staff interviews the facility failed to complete a Significant Change Minimum Data Set (SCMDS) within 14 days of the facility recognizing the resident had a significant change for 1 of 1 resident reviewed (Resident #1.) The facility reported a census of 45 residents.

Inspectors wroteBased on medical health record review (MHR) and staff interviews the facility failed to submit a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1 October 2024, within the required timeframe for 2 out of 15 residents reviewed (Residents #3, and #10). The facility census was 45.

Inspectors wrote2. Resident #7's MDS assessment dated [DATE] revealed the resident had impairments in short term and long term memory, moderate impairment for daily decision making, inattention, and disorganized thinking as indicated by the staff. The document revealed diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, and treatments included pressure reducing devices for chair and bed. On 3/31/25 at 11:37 AM observed an unidentified staff member push Resident #7 to the dining room in a Broda Reclining Wheelchair (w/c) wearing Prafo boots. On 3/31/25 at 12:43 PM observed Resident #7 in the living area in the Broda Reclining w/c wearing Prafo boots. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to follow physician's orders for blood pressure parameters and daily weights for 2 of 6 residents reviewed (Resident #2 and #3.) The facility reported a census of 45 residents.

Inspectors wroteBased on record and policy review and interviews the facility failed to implement restorative services for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 45 residents.

Inspectors wroteBased on the observation, staff interviews, and policy review the facility failed to reposition 1 of 3 reviewed (Resident #7). The facility reported a census of 45 residents.

Inspectors wrote2. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, had a diabetic foot ulcer, and had pressure reducing devices for chair, bed, applications of ointments/medications other than to feet, and dressings to feet. Resident #10's Care Plan, dated 3/3/25, revealed the resident was at moderate risk for pressure ulcers. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to provide interventions for pressure ulcer prevention for 1 of 3 residents reviewed, (Resident #1). Resident #1 had a pressure ulcer to the right heel and was found to be without his protective boots and without the ordered treatment dressing. The facility reported a census of 45 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to protect a resident from a possible accident and injury by pushing the resident in a wheelchair without foot rests for 1 of 5 residents (Resident #12). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 2 of 2 residents reviewed (Residents #10, #18). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) while providing wound treatments for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed, (Resident #31). At the time of survey, Resident #31 was found to be sitting in the recliner in his room for long periods of time with no pressure-reducing device on the seat. The resident had two open sores on his buttocks. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, record review, facility investigative file review, resident and staff interviews and policy review, the facility failed to ensure 2 of 3 residents (Resident #11 and #96) reviewed were free of accidents/hazards with transfers. The facility reported a census of 47 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to assure residents were free from significant medication errors for 1 of 22 residents reviewed, (Resident #30). The facility reported a census of 47 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 documented a diagnoses of Diabetes Mellitus (DM), renal insufficiency and hypertension. The MDS indicated the resident required the high risk drug class of insulin injections for DM management. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The Care Plan for Resident #30 showed the following related to DM: a. Diabetes medication of glucose tabs, glipizide and insulin ordered by the physician. b. Monitor and document side effects and effectiveness. The Physician Orders for Resident #30 showed the following: a. [...]

Inspectors wroteBased on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and/or the resident's responsible person when residents transferred out of the facility and failed to provide written notice of bed hold for 4 of 4 residents reviewed, (Residents #23, #24, #28 and #33). The facility reported a census of 47 residents.

Inspectors wroteBased on record review, staff interview and the MDS 3.0 Resident Assessment Instrument User's Manual the facility failed to complete and/or submit MDS assessments in a timely manner for 4 of 37 residents reviewed, (Resident #23, #36, #39 and #96). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical observation, record review and staff interview the facility failed to develop comprehensive care plans for continuous positive airway pressure (CPAP), pain management, urinary tract infection, catheter, and hospice services for 4 out of 22 residents reviewed, (Residents #21, #24, #28 and #33). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to develop resident-specific care plans for 4 of 22 residents reviewed, (Resident #31, #11, #39 and #32). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review facility failed to monitor for expired medications, and failed to document open dates on insulin medications for 6 of 6 resident reviewed, (Resident #31, #32, #47, #54, #30 and #27). The facility reported a census of 47 residents.

Inspectors wroteBased on record review, facility investigative file review, resident and staff interviews, and policy review the facility failed to treat 1 of 3 residents (Resident #5) with dignity while assisting with cares and during transfers. The facility reported a census of 47 residents.

Inspectors wroteBased on interview, policy review and record review the facility failed to complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 3 of 4 residents reviewed, (Residents #50, #51 and #149). The facility reported a census of 47 residents.

Inspectors wroteBased on facility record review and staff interviews the facility failed to complete a significant change MDS within 14 days of the facility recognizing the resident had a significant change for 1 out of 22 residents reviewed, (Resident #33). The facility reported a census of 47.

Inspectors wroteBased on interview, policy review and record review the facility failed to complete a Quarterly Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 3 of 3 residents reviewed, (Resident #19, #39 and #49). The facility reported a census of 47 residents. 1. Review of Resident #19's Minimum Data Set (MDS) tab in her Electronic Health Record (EHR) revealed a Quarterly MDS assessment was completed on 6/28/2024. A second Quarterly MDS assessment was completed on 11/29/2024. The Quarterly MDS assessment completed on 11/29/2024 was completed five months after the 6/28/2024 Quarterly assessment was completed. 2. Review of Resident #39's MDS tab in his EHR revealed an admission MDS assessment was completed on 7/10/2024. A Quarterly MDS assessment was completed on 12/6/2024. [...]

Inspectors wroteBased on clinical record review, facility policy and staff interview the facility failed to provide accurate assessments on residents to reflect the residents current needs for 1 of 22 residents reviewed, (Resident #33). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, facility policy and staff interview the facility failed to provide a written summary of the baseline care plan for 3 of 22 residents reviewed, (Resident #24, #28 and #41). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff followed physicians' orders for 2 of 22 residents reviewed, (Resident #31 and #39). Staff failed to contact the physician with high blood pressures for Resident #31. Resident #39 had an order for anti-anxiety medication, staff failed to utilize and document as ordered. The facility reported a census of 47 residents.

Inspectors wroteBased on interviews with staff and Hospice Nursing, record and medication review, the facility failed to assess residents and ensure they had appropriate interventions for 3 of 22 residents reviewed, (Resident #152, #33 and #24). Resident #11 had an unwitnessed fall that resulted in a fracture, staff failed to send her to the hospital for observation until 6 hours later and failed to document neurological assessments. Residents #33 and #24 missed medication doses because they were not available at the facility. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, record review, staff interviews and policy reviews, the facility failed to change and label oxygen tubing for 1 of 2 residents reviewed, (Resident #24). The facility reported a census of 47.

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify specific targeted behaviors related to high risk medications in 1 out of 7 sampled residents reviewed, (Resident #24). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident records reflected accurate care provided for 2 of 22 residents reviewed, (Resident #149 and #31). The facility reported a census of 47 residents.

Inspectors wrote2. Observation on 2/3/25 at 10:50 a.m, included observation of Resident #24's catheter bag laying directly on the floor. The catheter bag lacked a privacy cover. Facility did not provide a policy on catheter bags not touching the floor. Interview on 2/6/25 at 9:11 a.m., with the Director of Nursing revealed the catheter bag should not ever be on the floor. Based on observation, interview and record review the facility failed to implement infection control practices for 2 of 22 residents reviewed, (Resident #149 and #24). While staff provided nutrition and medications through a feeding tube, she failed to wear all of the required Personal Protective Equipment (PPE). The nurse stood on the resident's oxygen tubing while providing care to Resident #149. The urinary catheter bag for Resident #24 was laying on the floor. The facility reported a census of 47 residents.

Inspectors wroteBased on document review, resident interview, and staff interview the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility reported a census of 47 residents.

Inspectors wroteBased on document review, staff interview, and policy review the facility failed to properly review the facility assessment annually with the minimum staff required. The facility reported a census of 47 residents.

Inspectors wroteBased on document review, staff interview, and policy review the facility failed to properly monitor and identify current issues in a timely manner. The facility reported a census of 47 residents.

Inspectors wroteBased on document review, staff interview, and policy review the facility failed to establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 47 residents.

Inspectors wroteThe Infection Prevention and Control Program revealed the last revision date completed as March 2020. During an interview 2/13/24 at 1:04 PM, the DON/Infection Preventionist (IP) reported that she didn't know if the infection control policy got reviewed annually. During an interview 2/13/24 at 1:06 PM the Administrator and the DON said they should review the policy annually. They type the revision date on the form as to when it is reviewed. The Administrator acknowledged the Infection Control Policy listed the last revised March 2020. The Administrator added he expected the facility to review the infection control policy annually, sign, and date it when they reviewed the document. The Administrator explained they didn't have a policy to review as the facility followed the set of Federal regulations and standards of practice. [...]

Inspectors wroteBased on interview, record review and policy review the facility failed to ensure the Administration conducted annual ethics trainings and reviewed the ethics policy on an annual basis. The facility reported a census of 47 residents.

Inspectors wroteBased on record review and interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 4 out of 4 residents reviewed (Residents #11, #12, #124, and #151).

Inspectors wroteBased on record review and interview the facility failed to submit change of condition assessment information for 2 of 2 residents reviewed (Residents #14 and #136). After Residents #136 and #14 began hospice services, the facility failed to complete the Minimum Data Set (MDS) assessment within the required timeframe as directed by the The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual regarding a change in status.

Inspectors wroteBased on electronic health record review (EHR), policy review, and staff interviews the facility failed to complete quarterly comprehensive assessments for 4 of 4 residents reviewed (Residents #3, #4, #6, and #126) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3 Manual.

Inspectors wroteBased on chart review and interviews the facility failed to transmit Minimum Data Set (MDS) resident assessment information as directed by the The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual within 14 days from the date the Registered Nurse (RN) certifies completion of the Care Area Assessment for 4 of 4 residents (Residents #7, #8, #22, and #154) reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provided adequate fluids for 4 of 4 residents reviewed (Residents #14, #125, #145, and #159). When Resident #14 went to the hospital for high blood glucose levels, they diagnosed her with dehydration. Resident #125 required a feeding tube with free water 4 times a day. The Medication Administration Record (MAR) lacked documentation indicating they received the order as written. Residents #145 and #159 reported that their water pitchers did not get filled on a daily basis.

Inspectors wroteBased on observations, clinical record review, resident, and staff interviews, the facility failed to failed to implement offloading procedures to decrease pressure for 1 of 3 residents as directed by their Care Plan (Resident #137). Resident #137's Care Plan directed to use a pressure relieving pad while in his chair. Multiple observations revealed Resident #137 sat in his reclining chair (recliner) without a pressure relieving pad. Resident #137 reported his buttocks hurt.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff administered medications according to physician's orders for 2 of 2 reviewed (Resident #132 and #159). According to the Medication Administration Record (MAR) on the weekend of February 10th and 11th, Residents #132 and #159 did not get their scheduled insulin.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide accurate and timely assessment and interventions for 2 of 17 residents reviewed (Resident #14 and #3). Resident #14 had a diagnosis of type 2 diabetes. On the early morning of 11/16/23 she had a change in condition and staff failed to obtain a blood glucose level or set of vitals until 4 hours later. She was then sent to the hospital with Diabetic Ketoacidosis and a blood glucose level of 434 milligrams per deciliter (mg/dL) (normal range being 80-130 mg/dL). Resident #3 reported that she had pain at her stoma site and cream relieved the pain. Staff failed to provide the treatments to her stoma that provided her relief.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare, serve, and distribute food in accordance with professional standards. The facility reported a census of 47 residents.