Wachusett Manor

Inspectors wroteBased on record review, and interviews, the facility failed to provide notification of transfer and discharge to the State Office of the Long-term Care Ombudsman for five Residents (#51, #43, #53, #92, and #7) out of six applicable residents reviewed, out of total sample of 19 Residents, and one discharged Resident (#89) out of three discharge records reviewed. Specifically, the facility failed to send a copy of the notice of transfer and discharge to a Representative of the Office of the State Long-Term Care Ombudsman when Resident's #51, #43, #53, #92, #7, and #89 were transferred to the hospital.

Inspectors wroteBased on record review, and interview, the facility failed to notify the Physician of pertinent information for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5, the facility failed to notify the Physician as ordered, when the Resident's Finger Stick Blood Sugar (FSBS) level was greater than 350 milligrams per deciliter (mg/dl).

Inspectors wroteBased on record review, and interview, the facility failed to provide an adequate resolution of a filed grievance on behalf of one Resident (#4), out of a total sample of 19 residents. Specifically, for Resident #4, the facility failed to thoroughly review, investigate, adequately resolve a grievance, and provide a written grievance resolution to Resident #4 when the Resident had complaints of noise in their room at night that affected his/her sleep.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for one Resident #8), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the Resident's history of self-injurious behaviors.

Inspectors wroteBased on observation, and interview, the facility failed to adhere to infection control standards of practice, increasing the risk of contamination and spread of infections on one unit (second floor short hall unit) out of three units, and three resident rooms located on the second-floor short hall unit. Specifically, the facility failed to: -Ensure proper cleaning and disinfecting of shared resident equipment after use for residents who were on Enhanced Barrier Precautions (EBP- measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) when Nurse #1 completed vital signs for two residents. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had recently been readmitted with new diagnoses of aspiration pneumonia (infection caused by inhaling something other than air into the lungs), and pericardial effusion (fluid around the heart), the Facility failed to ensure nursing notified the Provider when he/she experienced further decline with a change in condition.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a full code, who during the evening shift (3:00 P.M. to 11:00 P.M.) on [DATE], was found unresponsive, pulseless with no respirations by the nursing staff, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although nursing staff initiated a Code Blue, called 911, and provided Cardiopulmonary Resuscitation (CPR), to him/her until Emergency Services arrived, nursing failed to obtain and use the facility's Automated External Defibrillator (AED) device, during the Code Blue.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to implement infection control practices designed to prevent development and transmission of infection and provide a sanitary environment for two Residents (#20 and #67) out of a total sample of 19 residents. Specifically, facility staff failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests in the main facility kitchen, on two units (Unit Two and Unit Four) and in the residents rooms for three Residents (#17, #69 and #290). Specifically, the facility staff failed to implement measures to eradicate and contain small flies located in the facility's main kitchen, the kitchenette on Unit Two, dining room on Unit Four, and in Resident's #17, #69 and #290 rooms, increasing the risk for contamination of clean surfaces and transmission of infectious pathogens.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a clean and homelike environment on one Unit (#4) out of three units observed. Specifically, the facility failed to ensure that the flooring in the Unit #4 multi-purpose room was in good repair and homelike condition.

Inspectors wroteBased on observation, interview, record, and policy review, the facility failed to provide care in accordance with professional standards of practice relative to providing a pressure redistribution cushion (cushion that spreads pressure more evenly across its surface to reduce the amount of pressure on any one part of the body) to a wheelchair when the Resident was at risk for skin breakdown for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5 the facility staff failed to: -Follow a Physician's order to provide a pressure redistribution cushion to the Resident's wheelchair. -Implement the Resident's care plan for a new cushion to the Resident's wheelchair. -Provide a pressure relieving device to the Resident's chair as indicated in the Minimum Data Set (MDS) Assessment and for the Resident who was assessed as being at a high risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for one Resident (#43) out of a total sample of 19 residents. Specifically, the facility staff failed to: -verify the Physician orders for the appropriate liter per minute (LPM- the flow rate that supplemental oxygen is set for delivery) of Oxygen when the Resident was ordered for seven (7) LPM of Oxygen. -ensure that Resident #43 was administered the appropriate liter flow for the oxygen delivery device (nasal cannula - a thin flexible tube that provides supplemental oxygen to patients through the nose via nasal prongs) being used when the Resident was found to be ordered for and administered greater than six (6) LPM of Oxygen that was not compliant with professional standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (#71) out of a total sample of 19 residents received trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to complete a trauma history assessment for Resident #71 who had a diagnosis of Post Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), placing the Resident at risk for re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for one Resident (#2) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain consent for dental services from Resident #2's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) in a timely manner after the HCP had been invoked (made active by the Physician).

Inspectors wroteBased on observation and interview, the facility failed to maintain resident wheelchairs in a clean and sanitary manner for two Residents (#291 and #293), out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Residents #291's wheelchair was clean, sanitary, and in good repair. 2. Resident #293's wheelchair was clean and sanitary.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the Resident's status for one Resident (#2) out of a total sample of 19 residents. Specifically, the MDS failed to accurately reflect that Resident #2 was diagnosed with Anxiety Disorder and had natural teeth that were broken.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided treatment and care that met professional standards of quality for one Resident (#89) out of one applicably sampled resident with a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of two total discharged residents sampled. Specifically, the facility failed to ensure its licensed nursing staff provided necessary and timely respiratory care, in an effective manner, when Resident #89 experienced a decline in respiratory status at 11:45 A.M. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided necessary respiratory care for one Resident (#89) with a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, of one applicably sampled resident, out of a total sample of two discharged residents. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide competent nursing staff to care for one Resident (#89), of one applicably sampled resident who had a tracheostoma (opening to make a direct airway through the trachea [windpipe]) and laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of two total discharged residents sampled. [...]

Inspectors wroteBased on interview, record review, and Facility Assessment Tool review, the facility failed to ensure its staff implemented the Facility Assessment Tool's staff training/education and competencies plan, and updated the Facility Assessment Tool to accurately reflect the resident population and care needs for day-to-day operations and medical emergencies for one Resident (#89) out of one applicably sampled resident with a laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of a total of two discharged residents sampled. [...]

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure its staff implemented an infection prevention and control program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff 1. implemented a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building's water system and cause lung infection) within the facility, and 2. implemented the use of personal protective equipment (PPE), to prevent the transmission of infection, while handling soiled linen in the facility laundry room.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure its staff maintained a system to track and accurately document staff COVID-19 vaccination status.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided an environment as free of accident hazard as possible for four Residents (#34, #56, #72, and #24) out of 24 total sampled residents. Specifically, the facility failed to provide: 1. adequate supervision and assistance for Resident #34 when the Resident with diagnosis of dementia, was being transported to an appointment outside the facility, and exited the transport van on the roadway, 2. adequate assistance to Resident #56 relative to eating when the Resident had dysphagia (difficulty swallowing) and was being physically assisted by a staff member to eat when the staff member was not trained in feeding assistance, 3. a smoking apron for Resident #72 when the facility identified the need for the Resident to wear a smoking apron when he/she actively smoked, 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff had the required members of the Quality Assessment (QA) and Assurance Committee attended two of the last four quarterly meetings. Specifically, the facility staff failed to ensure the Infection Preventionist (IP) attended, as required.

Inspectors wroteBased on policy review, record review and interview, the failed to ensure its staff maintained medical records that included documentation indicating that the Resident or Resident's Representative, had been provided education regarding the benefits and potential side effects of the COVID-19 vaccine, declined the vaccine or was administered the COVID-19 vaccine. Specifically, the facility staff failed to document the COVID-19 immunization status for four Residents (#34, #30, #63, and#82), out of five applicable sampled residents, in a total sample of 24 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure its staff provided a dignified environment for one Resident (#4) out of 24 sampled residents. Specifically, the facility staff failed to remove a bedpan, with feces in it, from the Resident's bed side table, that also had drinks for consumption on it.

Inspectors wroteBased on record review and interview the facility failed to ensure its staff notified the Physician in a timely manner, of Hospice recommendations related to pain and mood management, for one Resident (#88) out of 24 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff completed Significant Change in Status Assessments (SCSA) for two Residents (#88 and #22) out of 24 sampled residents, when they entered into Hospice services.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff completed discharge Minimum Data Set (MDS) assessments for two Residents (#59 and #46), as required, out of 24 total sampled residents. Specifically, facility staff failed to complete discharge MDS assessments for: 1. Resident #59 when he/she was discharged home from the facility, and 2. Resident #46 when he/she was discharged from the facility to another facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff accurately coded Minimum Data Set (MDS) assessments for three Residents (#58, #72, and #22) out of 24 total sampled residents. Specifically, facility staff failed to accurately code: 1. Resident #58 for wandering behavior on one comprehensive MDS assessment when the Resident demonstrated wandering during the observation period while at the facility, 2. Resident #72 as having current use of tobacco on one comprehensive MDS assessment when the Resident actively smoked during the observation period while in the facility, and 3. Resident #22 as using oxygen on one quarterly MDS assessment when the Resident used oxygen during the observation period while at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for one Resident (#38), out of 24 total sampled residents, relative to meal intake. Specifically, the facility staff failed to encourage the Resident to consume food, during two consecutive breakfast meals, when the Resident did not initiate self-feeding.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff 1. reviewed the comprehensive care plan with the Resident/Resident Representative at least quarterly, for one Resident (#24), 2. and failed to revise the comprehensive care plan for one Resident (#22) after admission to Hospice services secondary to a significant change in health status, out of 24 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure its staff offered a preferred activity of choice, based on the comprehensive assessment and care plan, for one Resident (#4) out of 24 sampled residents. Specifically, the facility failed to ensure its staff offered the Resident to go outside when the Resident communicated desire to go outside.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided vision services for one Resident (#41) out of 24 sampled residents.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure its staff evaluated the nutritional needs in a timely manner for one Resident (#75) out of one applicable sampled resident in a total sample of 24 residents, who was receiving oral food and feedings via gastrostomy (G-tube: an opening in the abdominal wall, made surgically for the introduction of food) tube. Specifically, the facility failed to ensure timely communication with the Registered Dietician (RD) to assess one Resident (#75) for an increase in G-tube feeding when the Resident had a history of weight loss, accepted limited food by mouth, and the Physician recommended the RD to assess the Resident for potential increase in G-tube feeding.

Inspectors wroteBased on policy review, observation, record review and interview, the facility failed to ensure its staff provided care for a peripherally inserted central catheter (PICC-catheter that enters the body through the skin and extends into the superior vena cava, to deliver medications for extended periods of time), for one Resident (#142), out of one applicable sampled residents, in a total sample of 24 residents. Specifically, the facility failed to ensure its staff entered Physician orders for care and services of the PICC onto the Medication Administration Record (MAR)/Treatment Administration Record (TAR) to ensure the nursing staff implemented the care as ordered.

Inspectors wroteBased on policy review, observation, record review and interview, the facility failed to ensure its staff provided adequate pain management for one Resident (#88) out of 24 sampled residents. Specifically, the facility failed to follow through, in a timely manner, with recommendations for pain management from the Hospice provider and failed to administer as needed (PRN) analgesic when pain was identified.

Inspectors wroteBased on policy review, observation, record review and interview, the facility failed to ensure its staff assessed one Resident (#4) out of 24 sampled residents, for the risk of entrapment from bed rails prior to installation.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided required Physician visits within the first 90 days of admission to the facility for two Residents (#26 and #35) out of 24 total residents sampled. Specifically, facility staff failed to ensure Residents #26 and #35 received Physician visits at least every 30 days during their first 90 days of admission to the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff updated one Resident's (#142) paper clinical record, related to the Advanced Directive order in a timely manner, to reflect the Resident's wishes to have Cardiac Pulmonary Resuscitation (CPR) administered in the event of cardiac or respiratory arrest, out of 24 sampled residents.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure its staff maintained medical records that included documentation indicating that the Resident or Resident's Representative, had been provided education regarding the benefits and potential side effects of the pneumococcal vaccine, declined the vaccine or was administered the pneumococcal vaccine. Specifically, the facility staff failed to document the pneumococcal immunization status for two Residents (#76 and #63), out of five applicable sampled residents, in a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure its staff completed an inspection of bed rails, to identify areas of possible entrapment, for one Resident (#4) out of 24 sampled residents.