Riverbend of South Natick

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that appropriate infection prevention and control measures were followed for one Resident (#18) out of a total sample of 13 residents. Specifically, for Resident #18, the facility failed to implement and adhere to Contact Precautions to reduce the potential spread of infection when the Resident was diagnosed with Scabies (skin infection/rash caused by a parasitic mite, that can be spread by skin-to-skin contact) putting staff, other residents, and visitors at risk for the spread of infection.

Inspectors wroteBased on observations, and interviews, the facility failed to post the required nurse staffing data daily in a prominent place, readily accessible to residents, staff and visitors on three out of three days observed. Specifically, the facility failed to: -Post nurse staffing data on 8/5/25, 8/6/25, and 8/7/25 in a prominent place in the facility as required. -Post nurse staffing data including the facility name, the current date, the total number and the actual hours worked by Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, in addition to the resident census.

Inspectors wroteBased on record review and interview, the facility failed to notify the Physician of a significant change in condition for one Resident (#3) out of a total sample of 13 Residents. Specifically, the facility staff failed to notify the Physician/ Nurse Practitioner (NP) so treatment could be altered when Resident #3 was identified with significant weight loss by the Registered Dietician.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one Resident (#27) was free from a potential restraint, out of a total sample of 13 residents. Specifically, the facility failed to assess the use of the right side of the bed positioned flush against the wall, preventing Resident #27 from exiting the right side of bed, being used as a potential restraint.

Inspectors wroteBased on policy, record review and interview, the facility failed to refer one Resident (#17) out of a total sample of 13 residents, for a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals are not inappropriately placed in long term care) Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen (a pre-admission screening process used to determine if a person has a diagnosis or suspected diagnosis of developmental disabilities/related conditions or mental illness) for mental illness (MI), intellectual disability, or related condition to determine if they require specialized services). [...]

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the plan of care was revised for three Residents (#8, #18 and #10), out of a total sample of 13 residents. Specifically, the facility staff failed to: 1. For Resident #8, revise the Resident's Incontinence Care Plan to reflect the current suprapubic catheter size. 2. For Resident #18, revise a Fall Care Plan after the Resident sustained a fall. 3. For Resident #10, ensure that the Resident and/or the Resident Representative were invited to participate in the Care Plan Conference Meetings.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to recognize and address nutritional needs timely when weight loss of greater than 10% was identified for one Resident (#3), out of a total sample of 13 residents. Specifically, the facility failed to: -notify the Registered Dietician (RD) and Physician/ Nurse Practitioner (NP) timely when the significant weight loss occurred, -implement a recommendation from the RD to obtain labs for Resident #3, -obtain a re-weigh and implement nutritional interventions timely, resulting in a two week delay of care.

Inspectors wroteBased on review and interview, the facility failed to provide evidence that the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to provide evidence that at least eight consecutive hours of RN coverage was provided on 5/4/24 and 5/11/24, when no Nurse staff waivers were in place, and there was no Director of Nursing (DON) serving as a charge nurse placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses' Aides (CNA) that the RN was responsible for overseeing with provision of resident care.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that the medication error rate was not five percent (5%) or greater when Nurse #1 made four errors out of 25 opportunities, resulting in a medication error rate of 16% for two Residents (#9 and #4). Specifically, Nurse #1 failed to: 1. For Resident #9, a. administer the correct dose of Cholecalciferol (Vitamin D3 - drug class vitamin used to treat Vitamin D deficiency) medication. b. observe and encourage the Resident to completely take all of his/her MiraLAX (used to treat constipation) medication. 2. For Resident #4, a. accurately check the Resident's blood pressure and heart rate as ordered prior to administering Metoprolol (used to lower blood pressure) medication. b. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that the facility residents were free of significant medication errors for one Resident (#4) out of five residents observed, out of a total sample of 13 residents, during the medication pass process. Specifically, for Resident #4, the facility staff failed to assess blood pressure and heart rate parameters as ordered prior to administering Metoprolol (used to treat high blood pressure) medication.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that infection control standards of practice were followed by Nurse #1 to prevent the spread of infections during the medication administration process for two Residents (#9 and #4) out of five residents observed, out of a total sample of 13 residents. Specifically, the facility failed to ensure that Nurse #1 performed appropriate hand hygiene before and after the medication administration process for Resident #9 and before and after the administration of eye drops for Resident #4.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to offer the Pneumococcal Vaccination as recommended for three Residents (#5, 10, and #18) out of five applicable Residents, in a total sample of 13 Residents, putting the residents at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that: 1. Resident #5's immunization consent form was complete and accurate, and the Resident was offered any eligible Pneumococcal Vaccination after admission to the facility. 2. Resident #10 was offered, received or declined any eligible Pneumococcal Vaccination after admission to the facility. 3. Resident #18 was offered, received, or declined any Pneumococcal Vaccination after admission to the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately code Minimum Data Set (MDS) assessments for one Resident (#27) out of a total sample of 13 residents. Specifically, for Resident #27, the facility staff failed to accurately code two consecutive MDS assessments relative to Hospice services.

Inspectors wroteBased on observation, policy review, interview, and record review, the facility failed to ensure its staff implemented appropriate infection control practices related to the use of Personal Protective Equipment (PPE) on two out of two units and also failed to implement a surveillance plan for the presence of Legionella. Specifically, the facility failed to: [...]

Inspectors wroteBased on record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. One of two nurses observed failed to administer medications, as ordered, for four of seven Residents (#16, #3, #6, #20) observed. The medication error rate was calculated at 18.52% with 27 opportunities for error.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff accurately executed advance directives (a written statement about a resident's wishes regarding medical treatment) for two Residents (#24 and #26) out of a total sample of 12 Residents. Specifically, 1) the facility failed to offer the opportunity to formulate an advanced directive for one Resident (#24), and 2) the facility failed to have an advanced directive reviewed and signed by a Physician for validation for one Resident (#26).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for the care of a urinary catheter (a tube placed through the urethra into the bladder to drain urine) for one Resident (#19) out of one applicable sampled resident, in a total of 12 sampled residents. Specifically, the facility failed to ensure the catheter tubing was securely placed to prevent possible dislodgement and trauma.

Inspectors wroteBased on record review, and staff interview, the facility and its staff failed to ensure that each Resident's medication regimen was modified in conjunction with residents, their families, and/or representative(s). Specifically, the facility staff failed to ensure Resident (#4's) psychotropic consent form was signed by the Resident or Resident's Legal Representative, reflecting the current dose of medication being administered for one out of a total sample of 12 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine dental services were provided for one Resident (#24) out of a sample of 12 residents.