Port Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure food was stored and distributed in accordance with professional standards of food safety to prevent the possible spread of foodborne illness in at risk residents. Specifically, 1. a. The facility failed to ensure food stored in the walk-in refrigerator was not stored and available after the use by date, b. The facility failed to ensure a loaf of bread was not stored after the use by date on one of three nourishments kitchens, and 2. Dietary Staff #1 a. failed to contain facial hair with a beard cover while in the food distribution area. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure treatment and care was provided in accordance with standards in quality of care for one Resident (#12), out of a total sample of 25 residents. Specifically, for Resident #12, who has a known risk and care planned for the risk of bruising, bleeding and skin tears, the facility failed to identify areas of injury on his/her lower right leg.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for one Resident (#54) out of a total sample of 25 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not directly touching the floor.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure for one Resident (#12), out of 7 residents reviewed for nutrition, out of a total sample of 25 residents, that a severe weight loss experienced by Resident #12 was addressed timely. Specifically, Resident #12's documented weight on 6/3/25 was 126.2 pounds and on 7/2/25 Resident #12's documented weight was 112.4 pounds, which is a body weight loss of 11.22 percent, which meets the criteria for severe weight loss. The clinical record failed to indicate a weight was retaken to confirm the weight loss, and the Registered Dietitian (RD) failed to conduct a nutritional assessment timely. A nutritional assessment by the RD was conducted 7/16/25, which was 14 days after Resident #12 experienced severe weight loss.

Inspectors wroteBased on observations, 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 Resident (#110) out of a total sample of 25 Residents. Specifically, the facility failed to change the PICC line dressing and measure the external length of the catheter as indicated in the physician's orders.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#26) out of sample of 25 residents. Specifically, the facility failed to obtain a physician's order for oxygen administration.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide care and services consistent with professional standards of practice for one Resident (#41) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, The facility failed to ensure ongoing assessment of the Resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The facility failed to ensure an emergency kit including clamps were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and 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, the facility failed to implement Enhanced Barrier Precautions for a central dialysis catheter for one Resident (#41), with a central dialysis catheter port, out of a total sample of 25 residents.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), and for one of three sampled employees (Certified Nurse Aide #1), and the Facility failed to ensure staff implemented and followed their abuse policy related to reporting of abuse allegations and employment requirements. 1) On 11/22/24, although Nurse #1 and the Charge Nurse were aware that Resident #1 had made an allegation that CNA #1 had slapped him/her on the arm during care, neither of them reported the allegation of abuse immediately to the Administrator or Director of Nurses, who were not made aware until three days later, and 2) prior to working at the facility, a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Certified Nurse Aide (CNA) #1, as required.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#104) out of a total sample of 26 residents. Specifically: 1a. For Resident #104, the facility failed to develop a plan of care for a stage 3 pressure ulcer that was present on admission to the facility and, 1b. For Resident #104, the facility failed to implement bed and chair alarms as indicated in the falls plan of care. Findings Include: Review of facility policy titled Interdisciplinary Care Planning, dated as revised 4/2024, indicated the following: -Care planning schedules are developed and coordinated by the Case Manager and/ or Social Services, in collaboration with the MDS (Minimum Data Set) Coordinator and nursing department. [...]

Inspectors wroteBased on observations, record review and interviews, the facility delayed the implementation of a wound treatment for two days after discovering a new wound for one Resident (#1) out of a total sample of 26 residents.

Inspectors wroteBased on observation and interviews the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure that insulin pens were labeled with resident name, open and expiration dates in one out of three medication carts observed. Findings Include: Review of facility policy titled Medication Storage in the Facility, dated as revised December 2019, indicated the following: -Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solution and strips, once opened require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. -Drugs dispensed in the manufacturer's original container will carry manufacturer's expiration date. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they implemented and followed their abuse policy, when after being made aware that Resident #1's family member physically restrained him/her in his/her wheelchair to prevent him/her from getting up, the Facility did not conduct an investigation into the incident and did not report the use of the restraint to their State Agency, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose care plan interventions included that he/she required the use of pressure sensitive alarms at all times when in bed and/or chair, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plan of Care, that his/her pressure sensitive alarms were in place and functioning, and as a result, Resident #1 experienced falls two day in a row and sustained skin tears with each fall.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls and required the use of pressure sensitive alarms in an effort to prevent falls, the Facility failed to ensure he/she was provided with the necessary functional safety devices to maintain his/her safety, when on 8/20/23 after he/she was found on the floor after a fall, it was determined that his/her pressure sensitive alarm was not in place, and on 8/21/23 the pressure sensitive alarm was knowingly disabled by a staff who left Resident #1 alone in the bathroom and he/she was found a short time later on the floor by staff. Resident #1 sustained multiple skins tears as result of both falls.

Inspectors wroteBased on record reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of Warfarin (an anticoagulant) which required blood laboratory work to be completed and reported to the physician so new orders could be obtained for the Warfarin, the Facility failed to ensure that he/she was free from significant medication errors, when due to a transcription error by nursing, the blood laboratory work was not ordered and obtained, therefore new physician orders for the Warfarin were not obtained, and Resident #1 went two weeks without receiving his/her Warfarin, placing him/her at increased risk for the development of blood clots.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure it maintained a complete and accurate medical record related to Activities of Daily Living care provided by Certified Nurse Aides.

Inspectors wroteBased on observation and interview the facility failed to store and prepare food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the plan of care was implemented for 1 Resident (#76) out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review the facility failed to revise the plan of care for one Resident (#105) out of a total of 25 sampled Residents.

Inspectors wroteBased on observation, record review the facility failed to provide care in accordance with professional standards for two Residents (#105 and #21) out of a total of 25 sampled residents. Specifically the facility failed to 1.) For Resident #105 the facility failed to obtain labs as ordered by the physician resulting in Resident #105 not receiving Warfarin (a blood thinning medication) for 10 days; and 2.) For Resident #21 the facility failed to ensure a.) Nurse #1 transcribed a physician's order accurately for a duoneb nebulizer (inhalation solution containing a combination of albuterol and ipratropium) and b.) failed to ensure nursing completed an accurate 24 hour review of physician orders for accuracy.

Inspectors wroteBased on interview and record review the facility failed to ensure that a system was developed to conduct comprehensive inspections of resident's beds, bed frames and bed rails to reduce the potential hazard of entrapment for beds in the facility. Specifically, the facility failed to identify a seven inch bed gap for one Resident (#122) out of a total sample of 25 residents.