The Center at Blue Hills

Inspectors wroteBased on interviews and records reviewed, for one of the three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure Resident #1 was free from physical abuse when, on 01/14/26 around 7:30 A.M., Certified Nurse Aide (CNA) #1 slapped Resident #1 in the face, which was witnessed by another staff member. Resident #1 was observed to have red marks on his/her face, told staff his/her face hurt and that he/she had been slapped. Based on the reasonable person concept, a cognitively impaired resident would experience emotional upset after being slapped by a caregiver.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the clinician (Physician, Nurse Practitioner, or Physician Assistant) making them valid for one Resident (#18), out of a total sample of 16 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit of three units in the facility. Specifically, the facility failed to ensure a utility room with hazardous items stored in it was not easily accessible to wandering residents on a Dementia Special Care Unit.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain the resident kitchenette in a clean and sanitary condition, and to ensure all food was properly labeled and dated and removed after three days in one of one kitchenette reviewed; and 2. Ensure the ceiling in the main kitchen was maintained in a safe sanitary condition to prevent flaking with potential to contaminate food and clean dishes below.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident (#37), out of a total sample of 16 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to address wound physician's recommendations timely for care and treatment of two Stage 3 pressure ulcers (full thickness tissue loss that extends through the skin into the fat and deeper tissue, but does not expose bone, tendon, or muscle) to the coccyx (tailbone) and right buttock.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for one Resident (#3), out of a total sample of 16 residents. Specifically, the facility failed to ensure a rationale was documented in the medical record for extending the use of Trazodone (anti-depressant) used for anxiety/agitation/insomnia.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Comprehensive MDS assessment within the required time frame for five Residents (#59, #20, #23, #42, #22), out of a total of 28 comprehensive assessments reviewed from September 2024 through October 9, 2024.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Quarterly MDS assessment within the required time frame for three Residents (#30, #21, #41), out of a total of 28 comprehensive assessments reviewed from September 2024 through October 9, 2024.

Inspectors wroteBased on interview, policy review and observation, the facility failed to 1) speak respectfully to 2 Residents (#24 and #39) and 2) serve meals to residents in a dignified manner, from a total sample of 33 residents.

Inspectors wroteBased on interview and observation, the facility failed to ensure window screens, sinks, bedroom doors, tiles and painted areas were in good condition.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to assess the use of a restraint for 5 Residents (#17, #43, #6, #47, #51) out of a total sample of 33 residents. Review of the facility's policy titled Physical Restraints, revision date 8/21, included the following: - Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets the following criteria: -Is attached to adjacent to the patient's body. -Cannot be removed easily by the patient -Restricts the patient's freedom of movement or normal access to his/her body. -Bedrails, position change alarms and positioning devices may be considered restraints. Positioning devises include pillows and barrier or scoop mattresses. All potentially restraining devices require assessment to determine if the device constitutes a restraint. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for 1) feeding assistance for 5 Residents (#1, #6, #15, #44 and #45), 2) elevating heels when in bed for 2 Residents (#43, #56) and 3) wandering behaviors for 1 Resident (#41) out of a total sample of 33 Residents. Findings Include: 1a. Resident #1 was admitted to the facility in December 2021 with diagnoses including Alzheimer's dementia, psychotic disorder and anxiety. On 7/19/23, at 8:27 A.M., the surveyor observed Resident #1 sitting in bed eating alone in the room. On 7/20/23, at 8:35 A.M., the surveyor observed Resident #1 sitting in bed eating alone in the room. Review of the medical record indicated a diagnosis of Dysphagia, Oropharyngeal Phase. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for 3 Resident's (#3, #54, #49), from a total sample of 33 residents. Specifically, the facility failed to ensure specific Resident names were not included in care plans.

Inspectors wroteBased on record review and interview, the facility failed to follow professional standards of nursing practice by not following physician orders regarding the timing of medication administration for 1 Resident (#5) out of a total sample of 33 Residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with eating for 1 Resident (#43) out of a total sample of 33 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff initiated Cardiopulmonary Resuscitation (CPR) appropriately for one Resident (#212) out of two closed Records. Specifically, after Resident #212 was found unresponsive and without a pulse, despite his/her code status of Do Not Resuscitate (DNR), staff initiated life saving measures in an attempt to resuscitate him/her, including administering CPR and calling 911. When staff determined that Resident #212 was a DNR, staff terminated CPR before Emergency Medical Staff (EMS) arrived.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure 1 Resident (#5) was wearing a wanderguard to prevent possible elopement, out of a total sample of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to develop a dementia care plan with measurable goals and interventions to address the care and treatment for a resident with dementia for two Residents (#57 and #262) out of a total sample of 33 residents. 1. Resident #57 was admitted to the facility in May 2022 with diagnoses including, dementia with behavioral disturbances, mood disorder with depressive features, congestive heart failure, and muscle weakness. Review of Resident #57's Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 0 out of a possible 15 indicating severe cognitive impairment. Further review indicated Resident #57 had daily physical behaviors towards others, and daily verbal behaviors towards others. The MDS further indicated Resident #57 received daily antipsychotic medications and daily antidepressants. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow the pharmacist's recommendations in a timely manner and have the physician review recommendations for 1 Resident (#41) out of a total same of 33 residents.

Inspectors wroteBased on observation and interview, the facility failed to follow proper infection control practices during dining for the residents on the East and North units.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure access to call lights or call bells for two Residents (#59 and #13) of a total sample of 33 residents.

Inspectors wroteBased on record review and interview, the facility failed to meet the obligation to issue to residents who received services under Medicare Part A, a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), which informs a resident of his/her potential liability for payment and related standard claim appeal rights, for 3 of 3 records reviewed.