Premier Healthcare at Harrington House

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had reported to nursing at breakfast time and again at lunch time, that he/she was unable to grasp his/her utensil which was a change for him/her, the Facility failed to ensure nursing notified his/her Physician and Health Care Proxy (Family Member #1) in a timely manner of his/her change in condition. Resident #1 was subsequently transferred to the Hospital Emergency Department (ED) around dinner time for evaluation of his/her complaints and was admitted .

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#7), out of a total sample of 18 residents, was offered devices (hearing aids or amplifier) to assist with communication.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic was effective in treating the identified bacteria after the culture and sensitivity (C&S) report indicated high level of resistance and failed to notify physician of ongoing urinary tract symptoms for one Resident (#33), out of a total sample of 18 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of two nurses observed during the medication pass made three errors out of 31 opportunities, resulting in a medication error rate of 9.68%. Those errors impacted two Residents (#68 and #32). Specifically:a. For Resident #68, the nurse administered the wrong aspirin and failed to administer a lidocaine patch (local anesthetic for pain management) as ordered; andb. For Resident #32, the nurse administered the wrong aspirin.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in one of two medication carts observed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to follow proper hand hygiene protocols while administering medications for two Residents (#5 and #68), out of three residents observed during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program that promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Specifically, the facility failed to ensure:1. Resident #33 received an antibiotic that was effective in treating an infection following a culture and sensitivity; and2. Resident #27's antibiotic use was reviewed for appropriateness for continued use following a culture with no growth of bacteria identified.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they reported an allegation of abuse to the Department of Public Health (DPH) within two hours, as required. On 06/15/25, Resident #1 was observed with an injury of unknown origin and were also made aware of an allegation of physical abuse related to the injury, the Facility did not report the incident to DPH, until 06/17/25, 48 hours after the injury had been identified.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who was found on the floor on 07/19/25 after an unwitnessed fall, the Facility failed to ensure he/she was provided care and treatment that met professional standards of nursing practice related to initial and ongoing assessments, and physician notification.

Inspectors wroteBased on observation, interview, and document review, the facility failed for one Resident (#77), out of a sample of 18 residents, to ensure the Resident received consistent care and treatment to prevent the further deterioration of a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel that went from dime sized and intact on 3/29/25 to quarter sized and open with drainage on 4/3/25.

Inspectors wroteBased on interview and review of the Health Care Facility Reporting (HCFS-State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator and Director of Nursing (DON) occurred.

Inspectors wroteBased on records reviewed and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; 3. For Resident #41, ensure Gastrostomy tube (G-tube: [...]

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use.

Inspectors wroteBased on observation, interview and record review the facility failed to develop, implement and individualize comprehensive care plans for four Residents (#10, #29, #12, and #73), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, a comprehensive care plan was developed to address the use of Quetiapine Fumarate (Seroquel-antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #29, a comprehensive care plan was developed to address the use of Risperdal (antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, for four Residents (#41, #63, #5 and #10) of 18 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #41, a. to ensure feeding tube formula was administered per physician's orders, and b. to ensure a dietary consult was obtained as ordered by the Physician; 2. For Resident #63, to ensure a physician's order was obtained prior to sending him/her to the hospital; 3. For Resident #5, to ensure the air mattress was set according to physician's orders and accurately documented in the medical record; and 4. For Resident #10, a. to ensure medication was administered as ordered; b. to ensure the air mattress was set according to physician's orders and accurately documented in the medical record.

Inspectors wroteBased on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#60 and #10), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure a recommendation from June 2024 left by the consultant pharmacist for Resident #60 to potentially reduce their medication load of Famotidine (a medication that decreases the amount of acid the stomach produces) from twice a day to once a day; and 2. For Resident #10, to ensure the August, September and October 2024 consultant pharmacist recommendations were acted upon timely to clarify the need for two as needed orders for Duoneb (inhalation solution to help open the airways in the lungs).

Inspectors wroteBased on record review and interview, the facility failed to ensure for two Residents (#79 and #73), out of a total sample of 18 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #79, to ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medications; and 2. For Resident #73, to: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise their rights for two Residents (#77 and #5), out of a total sample of 18 residents. Specifically, the facility failed to ensure that for: 1. Resident #77, the legal guardian was provided information upon admission to sign or verbally consent to treatment at the facility and sign or consent verbally for a wound consultant; and 2. Resident #5, the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was provided information upon admission to sign or verbally consent to treatment at the facility including for the use of bilateral side rails.

Inspectors wroteBased on document review and interview, the facility failed to ensure the legally responsible representatives were notified of changes in a resident's condition for two Residents (#77 and #44), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Inform the legal guardian of Resident #77 of the development of a facility acquired deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel on 2/2/25 or of the physician evaluation of the area on 2/4/25; and 2. Notify the Health Care Proxy (HCP) of Resident #44 of a significant weight loss.

Inspectors wroteBased on document review and interview, the facility failed for one Resident (#77), out of a total sample of 18 residents, to involve the Resident's legal guardian in the baseline care plan process and offer or provide them with a copy of the baseline care plan summary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate alternatives were attempted prior to installing a side or bed rail and risks and benefits of bed rails were reviewed with the resident and/or resident's representative and informed consent obtained prior to installation of bed rails for two Residents (#79 and #5), out of a total sample of 18 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required for two Residents (#10 and #17) out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, medication was not left unattended in the Resident's room; and 2. For Resident #17, ensure a medicated cream was not left unattended in his/her room.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal immunizations as requested/consented for three Residents (#10, #14, and #17), out of a total sample of five residents.

Inspectors wroteBased on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for two Residents (#10 and #17), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for two Residents (#41 and #44), from a sample of 18 residents, and for one Resident (#86) of two closed records reviewed. Specifically, the facility failed to ensure: 1. For Resident #41, the MDS accurately reflected his/her psychiatric diagnosis; 2. For Resident #44, the MDS accurately reflected his/her psychiatric diagnosis; and 3. For Resident #86, the MDS accurately reflected the Resident's discharge status.

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the care plan for one Resident (#10), out of a total sample of 18 residents. Specifically, the facility failed to ensure the care plan for pressure ulcers was updated to reflect the resolution of two pressure ulcers (a localized area of skin damage that develops when prolonged pressure is applied to the body).

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired, unable to make his/her needs known to staff and was dependent on staff for all care, the Facility failed to ensure Resident #1 was free from restraints, when on 09/16/24, he/she was found in the day room by the Unit Manager in his/her Broda chair which was fully reclined, with a couch up against the left side of the Broda chair, and the right side was positioned against the wall, which restricted his/her movements on either side.

Inspectors wroteBased on observation, interview, records reviewed, and policy review, the facility failed to provide care, consistent with professional standards of practice for four Residents (#60, #12, #11, and #46), out of a sample of 19 residents. Specifically, the facility failed to: 1. Monitor and care for peripherally inserted central catheter lines (PICC- a catheter that is inserted into the vein and goes up to your heart to deliver medication) for two Residents (#60 and #12), out of two of two PICC lines reviewed. Specifically, the facility failed to: A. For Resident #60, to obtain orders for care of a PICC line, including dressing change, external length measurements, arm circumferential measurements, and ensure the lumen was capped; and B. [...]

Inspectors wroteBased on interview, record review, and observations, the facility failed to maintain hearing at an optimal level to maintain the highest practical emotional level for one Resident (#52), out of 19 sampled residents. Specifically, the facility failed to continue to assess the Resident for wax build up in the right ear and assist Resident #52 in obtaining audiology (hearing) services for a hearing evaluation to replace a lost hearing aid for two months, resulting in Resident #52 being isolated in his/her room due to hearing deficits.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 4 nurses observed made 5 errors out of 39 opportunities, resulting in a medication error rate of 12.82%. Those errors impacted four Residents (#27, #19, #322, and #221), out of six residents observed.

Inspectors wroteBased on observation, interview and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in two out of two nourishment kitchens. Specifically, the facility failed to properly label and date facility and resident food items and discard perishable food items by the use-by date.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to adhere to infection control practices to reduce potential transmission of infection for one Resident (#60), out of 19 sampled residents. Specifically, for Resident #60, the facility failed to: - Ensure contact precautions were maintained for methicillin resistant staphylococcus aureus (MRSA- type of staph bacteria that is resistant to certain antibiotics) in the left hip abscess, signage was posted at the entrance to the room, and personal protective equipment (PPE) was readily available outside the room, and - Ensure PPE was worn by staff when providing care to Resident #60 who was on Transmission-Based Precautions (TBP, used for patients who may be infected or colonized with certain infectious agents requiring additional precautions to prevent the spread of infection).

Inspectors wroteBased on record review and interview, the facility failed to assist a visually and hearing-impaired resident file a grievance for a lost hearing aid the staff were aware was missing for two months for one Resident (#52), out of a total sample of 19 residents.

Inspectors wroteBased on observations, interviews, policy review, and records reviewed, for two Residents (#15 and #60), out of 19 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #15, to develop and implement a care plan for the use of anticoagulant medication (used to prevent the blood from clotting, a blood thinner); and 2. For Resident #60, to develop and implement a care plan for care and monitoring of a peripheral inserted central catheter (PICC) line (A catheter that is inserted into the vein and goes up to your heart to deliver medication).

Inspectors wroteBased on policy review, interviews, and record reviews for one Resident (#30) of 19 sampled residents, the facility failed to provide adequate supervision to prevent accidents. Specifically, the facility failed to ensure falls were thoroughly investigated and interventions were initiated/implemented to prevent further falls.

Inspectors wroteBased on record review, employee education file review, and interviews, the facility failed to ensure four of five nurses reviewed completed their competencies for intravenous (IV) skills training. Specifically, the facility failed to: 1. Ensure three of three graduate nurses (practicing nursing as graduates and students in their last semester of nursing education programs in accordance with the guidance from the Massachusetts Board of Registration and Nursing (BORN)) completed their training and passed the competencies to provide direct care for IV care to residents residing in the facility; and 2. Ensure one nurse completed her competencies for intravenous treatment while overseeing one of the new graduate nurses providing care to a patient with a PICC line.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure targeted behaviors and signs and symptoms of adverse reaction/side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one Resident (#52), out of a total sample of 19 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary environment for one Resident (#23), out of a total sample of 19 residents. Specifically, the facility failed to maintain the cleanliness of the Resident's room to avoid a strong smell of urine for four days of survey.