St. Patrick's Manor

Inspectors wroteBased on record review, and interview, the facility failed to provide care consistent with professional standards of practice relative to the administration of prescribed medication for one Resident (#145) out of a total sample of 36 residents. Specifically, for Resident #145, the facility failed to administer a Physician ordered antihypotensive medication (used to treat low blood pressure) as needed (PRN) when Systolic Blood Pressure (SBP - the top number of the blood pressure reading which indicates the force of circulating blood pushing against the artery when the heart beats) measurements were documented below 100 mmHg (millimeters of mercury) for the Resident.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that Advance Directives (a written statement about a resident's wishes regarding medical treatment) were accurately executed for one Resident (#411) out of a total sample of 36 Residents. Specifically, for Resident #411, the facility failed to: -offer the Resident/ Responsible Party the opportunity to formulate and/or review an Advanced Directive for the Resident. -obtain a Physician's order to indicate an accurate code status when the Resident was admitted to the facility with an illegible Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form and a handwritten, incomplete code status card.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#232), out of a total sample of 36 residents, was free from physical restraints. Specifically, the facility failed to ensure that Resident #232 was assessed for the use of a potential restraint (two stationary chairs), which were positioned in a way to prevent the Resident from moving freely around the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance for activities of daily living (ADL - basic life care tasks that individuals perform on a daily basis to maintain their well-being which include grooming) for two Residents (#164 and #556) out of a total sample size of 36 residents. Specifically, the facility failed to: 1. For Resident #164, ensure the Resident was offered and/or provided with grooming of facial hair when the Resident was dependent on facility staff for assist with grooming. 2. For Resident #556, ensure the Resident was offered and/or provided grooming of the fingernails when the Resident was dependent on facility staff for grooming.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that assistive devices to maintain hearing and enhance communication were utilized for one Resident (#234), out of a total sample of 36 residents. Specifically, for Resident #234, the facility failed to ensure that ordered hearing aids were applied daily when the Resident required staff assistance for insertion and manipulation of the hearing aids so he/she could maintain hearing and communication abilities. Finding Included: Review of the facility policy titled Hearing Aid Placement, last revised 11/2022, indicated the following: -The facility will provide a system to safely maintain resident hearing aids in support of their resident rights and quality of life. -Hearing aid placement and removal will be documented on the electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (nutrients provided directly into the stomach), for one Resident (#111) out of a total sample of 36 residents. Specifically, for Resident #111, the facility failed to ensure that enteral feeds and fluids being administered to the Resident were labeled and dated as appropriate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services that were consistent with professional standards of practice, for one Resident (#246), out of a total sample of 36 residents. Specifically, for Resident #246, the facility failed to ensure that the Resident's nebulizer setup equipment was appropriately labeled and dated and stored in a storage bag to prevent equipment contamination.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that medications were stored in a secure manner in one medication storage room (Sacred Heart Unit) out of four medication storage rooms observed, out of a total of eight medication storage rooms. Specifically, the facility failed to ensure that only authorized personnel had access to the medication storage room where prescription medications were stored on the Sacred Heart Unit.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a written notification of transfer or discharge was completed for one Resident (#156) out of a total sample size of 36 Residents. Specifically, the facility failed to: 1. Provide the Resident/Resident Representative with written notice of transfer or discharge when the Resident was transferred to the hospital. 2. Notify the Office of the State Long-Term Care Ombudsman of the Resident's transfer to the hospital.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a Bed Hold Policy Notice was issued upon transfer to the hospital for one Resident (#156) out of a total sample of 36 Residents. Specifically, for Resident #156, the facility failed to provide the Resident/Resident Representative with written notice of the facility's bed-hold policy when the Resident was transferred to the hospital.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two Residents (#253 and #254) out of three closed records reviewed. Specifically, the facility failed to ensure that MDS assessments for Resident's #253 and #254 were completed accurately, relative to discharge location.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care and Plan of Care [NAME], indicated he/she required extensive assistance from two staff members during transfers for safety, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plans of Care, when on 07/03/24, CNA #1 transferred Resident #1 using a Sit/Stand Lift device (lift device that helps individuals who have difficulty standing up, from a seated position), without having another staff member present to assist her with the transfer, Resident #1 became weak during the transfer, started to slide out of the lift seat, CNA #1 then tried to lower him/her to the floor, Resident #1 immediately complained of pain, was diagnosed with a right femur (thigh bone) fracture and required transfer, with admission to [...]

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 of falls, was known to have poor safety awareness, weakness due to a stroke and required the assistance of two staff members for transfers, the Facility failed to ensure Resident #1 was provided with the necessary level of staff assistance during a transfer to prevent an incident/accident resulting in a serious injury. [...]

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #2), whose primary spoken language was not English, the Facility failed to ensure he/she was free from abuse, when on 4/08/24, during the evening shift, when Resident #2 approached Nurse #1, who was in the hallway at the medication cart, to ask for his/her supplement, Nurse #1 yelled at Resident #2 in a humiliating and verbally aggressive manner saying, you are in America now, you need to learn to speak English! The altercation was witnessed by two other residents, who said Resident #2 was upset and crying after Nurse #1 yelled at him/her.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 4/08/24 during the evening shift after the Nurse Supervisor received a report of an allegation of abuse from Nurse #2 that Nurse #1 had been verbally abusive towards to Resident #2, the Nurse Supervisor failed to immediately notify the Administrator and Director of Nursing (DON) of the alleged abuse, and did not suspend Nurse #1, as a result Nurse #1 continued to work the overnight shift (11:00 P.M. to 7:00 A.M.) providing care to Resident #2 and other residents, placing them at risk for the potential for further abuse.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure that residents were treated with dignity during communal dining on one Unit (Sacred Heart), out of eight units observed. Specifically, the facility staff failed to be in a seated position while assisting Resident #96 during mealtime. Findings Include: Review of the facility policy titled Assisted Dining Totally Dependent on Staff for Dining last revised June 2021, indicated the following: -Staff will provide the necessary level of assistance to those residents who are unable to feed themselves or who need assistance or encouragement to eat. -Staff will place tray within view of the resident. -Staff will sit down and make eye contact while assisting the resident. [...]

Inspectors wroteBased on interviews, policy and record review, the facility failed to notify the Physician of a significant change in condition for one Resident (#28) out of a total sample of 35 residents. Specifically, the facility failed to notify the Physician to allow for re-evaluation and the potential need to alter the treatment plan, on four occasions when blood sugar values were high for Resident #28.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to adhere to infection control standards and implement their policy relative to Transmission-Based Precautions ([TBP] Isolation Precautions: actions implemented in addition to standard precautions based upon means of transmission [ .Droplet] in order to prevent or control infections) for two Residents (#149 and #108) out of five applicable residents, in a total sample of 35 residents. Specifically, the facility failed to ensure that Isolation Precautions remained in effect for the required duration for Residents #149 and #108, after both Residents tested positive for COVID-19.