Southbridge Rehabilitation & Health Care Center

Inspectors wroteBased on interviews, and record review, the facility failed to ensure one Resident (#107) out of a total sample of 26 residents, was seen by a Physician at the required regulatory frequency for physician visits. Specifically, the facility failed to ensure Resident #107 was seen by a Physician:-for the Resident's initial visit following admission to the facility.-for alternating visits with the Nurse Practitioner (NP) every 30 days for the first 90 days following admission to the facility.-for alternating visits with the NP every 60 days, after the Resident was in the facility for 90 days.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to provide a clean, sanitary or homelike environment for three Residents (#73, #9 and #52) out of a total sample of 26 residents, and in five rooms on two units (Second Floor and Third Floor) out of three resident units to prevent the potential for the spread of infection and maintain resident safety. Specifically, the facility failed to: 1. for Resident #73, clean and maintain a wheelchair in good condition on the Third Floor unit. 2. maintain privacy curtains in a clean and sanitary manner for three rooms out of twelve rooms observed on the Second Floor unit. 3. for Resident #9 and Resident #52, ensure window curtains were maintained in homelike condition on the Third Floor unit.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a grievance was initiated for prompt resolution relative to missing personal items for one Resident (#39) out of a total sample of 26 residents. Specifically, the facility failed to assist Resident #39 in appropriately filing a grievance when he/she reported missing two personal blankets to staff, staff was unable to find the missing blankets and did not report the Resident's complaint and missing personal items to the facility grievance officer as required.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure one Resident (#129) out of a total sample of 26 Residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #129's wheelchair brakes were unlocked while he/she was seated at a table when the Resident was unable to release the wheelchair brakes independently and was unable to move him/herself from the table.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that services were provided to maintain hearing abilities for one Resident (#108) out of a total sample of 26 residents. Specifically for Resident #108, the facility failed to assist with providing routine audiology care, when the Resident Representative consented to and requested audiology care services and the Resident was diagnosed with bilateral hearing loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two Residents (#55 and #37) and on three units (Second Floor, Third Floor and Forth Floor) out of three total units observed. Specifically, the facility failed to: 1. maintain comfortable water temperatures for bathing in resident rooms and unit shower rooms, resulting in Resident #55 and #37 not receiving showers as desired and requested due to cold water temperatures. 2. maintain comfortable water temperatures in resident rooms and for three of three unit shower rooms as needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement the comprehensive person-centered plan of care for two Residents (#88, #104) out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #88, implement the fall risk intervention for non-skid strips to the Resident's bedside and bathroom placing the Resident at risk for falls and injury. 2. For Resident #104, implement the nutritional risk intervention for a lip plate with meals placing the Resident at risk for calorie deficit.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate medical records for two Resident's (#77 and #5) out of a total sample of 26 residents. Specifically, the facility failed to: 1. for Resident #77, maintain documentation relative to behavioral health services that the Resident was receiving from a consulting firm. 2. for Resident #5, document that Physician/NPP was notified when Resident #5 had a significant change in condition relative to: A) blood sugar readings greater than 350 mg/dL (milligrams per deciliter) as indicated by a Physician's order, and B) when a laboratory value for Hemoglobin A1C (test that measures the average blood sugar level over the past three months) was out of normal range and noted as high, putting the resident at risk for complications related to hyperglycemia (high blood sugar levels).

Inspectors wroteBased on observation, record review, and interview, the facility failed to preserve the dignity of one Resident (#107) out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #107's wheelchair was maintained in a clean manner for use by the Resident.

Inspectors wroteBased on record review and interview, the facility failed to resolve a grievance timely for one Resident (#40), out of a total sample of 26 residents. Specifically, the facility staff failed to reimburse Resident #40 timely when money was reported missing, an investigation was completed, and the grievance was resolved 80 days after the initial grievance was filed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#81 and #70), out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #81, ensure a Physician's order was in place for the use of oxygen (O2) therapy. 2. For Resident #70, ensure that oxygen therapy was administered as ordered by the Physician.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one Resident (#24) was free from the use of unnecessary medications out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #24 did not receive extra doses of Insulin (medication used to control elevated blood sugar levels) when his/her blood sugar was under the 150 mg/dL (milligram per deciliter) level specified by the Physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored in a secure and safe manner, and according to professional standards of practice in the second-floor medication storage room. Specifically, the facility failed to store Lorazepam Concentrated Oral Liquid (controlled substance medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to treat anxiety disorders) in a safe manner when the Lorazepam was stored in a black metal box that was not fixed (could be removed) to the inside of the medication refrigerator in the second-floor medication storage room.

Inspectors wroteBased on interview, and record review, the facility failed to implement an Antibiotic Stewardship Program for one Resident (#52) out of a total sample of 26 residents. Specifically, for Resident #52, the facility failed to ensure that documentation was reviewed for signs and symptoms of infection prior to requesting an order for antibiotics from the Physician and/or Non-Physician Practitioner (NPP) and administering antibiotics for a suspected urinary tract infection (UTI).

Inspectors wroteBased on record review, and interview, the facility failed to offer the Pneumococcal Vaccination as recommended to one Resident (#104), for five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #104 was offered the Pneumococcal Conjugate Vaccine (PCV- a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a system to conduct regular maintenance and inspections of all bed frames, mattresses, and bed rails (side rails) as part of a regular maintenance program to identify areas of possible entrapment for two Residents (#5 and #70) out of three applicable residents for bed rail use, out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #5, provide inspection documentation for the Resident's bed frame, mattress, and side rails. 2. For Resident #70, provide documentation that the Resident's bed frame, mattress, and side rails were regularly inspected.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded for one Resident (#84) out of a total sample of 26 residents. Specifically, the facility staff incorrectly coded Clopidogrel (an antiplatelet [prevents platelets from sticking together] medication) as an anticoagulant on the MDS.

Inspectors wroteBased on observation and interview, the facility failed to post required nurse staffing information on a daily basis. Specifically, the facility failed to include daily posting of the following: -the resident census information on the daily posting for the facility nurse staffing. -total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in health status, and had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing notified his/her Health Care Agent (HCA) in a timely manner, when on 11/22/24, Resident #1 required administration of oxygen therapy during the overnight shift due to low oxygen saturation levels, that was new for him/her, however his/her HCA was not notified until the day shift, when he/she was transferred to the Hospital Emergency Department (ED) for evaluation.

Inspectors wroteBased on record review, and interview, the facility failed to accurately code Minimum Data Set (MDS) assessments for four Residents (#87, #94, #121, and #25) out of a total sample of 26 residents. Specifically, the facility staff failed to accurately code: 1. for falls for Resident's #87 and #94 2. for visual acuity for Resident #121 3. for administration of antipsychotic medication for Resident #25

Inspectors wroteBased on record review and interview, the facility failed to ensure that two residents (#62 and #90), in a total sample of 26 residents, were seen by a Physician for required visits. Specifically, the attending Physician failed to conduct required visits at least every 30 days for the first 90 days after admission and at least 60 days thereafter, with alternate visits by a Nurse Practitioner (NP). Findings Include: 1. Resident #62 was admitted to the facility in December 2022 with diagnoses including Bipolar Disorder, generalized Anxiety Disorder, major Depression, and Dementia with Lewy Body (a type of progressive Dementia that leads to a decline in thinking, reasoning and independent function). Review of the medical record indicated the following visits: [...]

Inspectors wroteBased on observation, policy review, and interview the facility failed to ensure that medications were stored and labeled appropriately for two of six applicable medication carts, and that medications were labeled appropriately for one of three applicable medication storage rooms. Specifically, the facility staff failed to: 1. Store and secure medication in the medication cart before stepping away from the medication cart. 2. Label [NAME]-dose vials of medication at the time that the vial was first opened.

Inspectors wroteBased on observation and interview the facility failed to ensure that resident identifying information on the medication cart computer screen was secured when the Nurse stepped away from the cart.

Inspectors wroteBased on record review and interview the facility failed to maintain the documented clinical transfer paperwork to the hospital in the resident's medical record as required for three Residents (#35, #40 and #96) out of a total sample of 26 residents. Specifically, the facility failed to maintain the appropriate documentation in Resident's (#35, #40 and 96) clinical record that had been communicated to the receiving health care provider to ensure a safe and effective transition of care.

Inspectors wroteBased on record review, and interview, the facility failed to notify the Resident, the Resident Representative and the Ombudsman of the Resident's transfer from the facility to the hospital in writing as required for two Residents (#78 and #117), out of a total sample of 26 residents.

Inspectors wroteBased on record review, policy review and interviews the facility failed to issue the written Bed Hold Policy as required to three Residents (#35, #78 and #117) and/or their Representatives, out of a total sample of 26 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein and into the central vascular system to administer intravenous [IV] treatments over a long period of time) for one applicable Resident (#20), in a total sample of 26 residents. Specifically, the facility staff failed to ensure that weekly PICC line dressing and measurements were obtained as ordered to monitor for infection, infiltration (when fluid leaks out into the tissues under the skin) and migration (movement).

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to provide care consistent with professional standards for one Resident (#117), who required Hemodialysis (a process for purifying blood of a person whose kidneys are not working normally, also referred to as dialysis) out of a total sample of 26 residents. Specifically, the facility staff failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that records were reviewed monthly by a consultant Pharmacist and monthly Medication Regimen Review (MRR) recommendations were reviewed timely and implemented as required for two residents (#40 and #62) out of a total sample of 26 residents. Specifically, 1. For Resident #40, the facility failed to ensure that the Pharmacy recommendations were reviewed by a Physician as required. 2. For Resident #62, that documentation of recommendations during a monthly MRR were maintained and that recommendations were submitted to the Physician for review.

Inspectors wroteBased on interview and record review, the facility failed to implement a Physician order for one Resident (#120), out of a total sample of 26 residents. Specifically, the facility failed to transcribe an order for Effexor 75 milligrams (mg) to be discontinued after the Psychiatrist ordered the change and the Nurse Practitioner (NP) agreed with the change recommendation.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records for one Resident (#20) out of a total sample of 26 residents. Specifically, the facility staff signed off on the Treatment Administration Record (TAR) that a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) line dressing was changed, when it had not been changed for the Resident.