Winthrop Health and Rehabilitation

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Reporting and Investigating Abuse, the facility failed to report allegations of abuse timely for two of 41 sampled residents (R) (R71 and R49) related to falls.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to conduct a thorough investigation of a fall with a major injury that resulted in a fracture for one resident (R) (R71) reviewed for falls.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration-General, the facility failed to ensure the medication error rate was 5% (percent) or less. A total of nine errors of 33 opportunities were observed for three of 10 residents (R) (R27, R3, and R31) during medication administration for a total error rate of 27.27%.Findings Include:Review of the facility policy titled Medication Administration-General revealed under Guideline: .Medications are administered within 60 minutes (one hour) BEFORE OR AFTER scheduled time. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing center. Certified Medication Aide (CMA) BB was observed to give R27, R3, and R31 medications late. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Pharmacy Services, Controlled Substance Medication Accountability, the facility failed to ensure controlled medication shift counts were documented with nurse signatures on two of two nurse medication carts. The deficient practice had the potential for missing medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Storage Areas, the facility failed to properly store opened food items in the walk-in refrigerator, walk-in freezer, and dry storage area. The deficient practice had the potential to affect all 67 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations, staff interviews, review of the facility policies titled, Skilled Inpatient Services, Infection Prevention Plan and Skilled Nursing Services, Wound Care, and review of the facility-provided document titled Enhanced Barrier Precautions, the facility failed to ensure nursing staff implemented Enhanced Barrier Precautions (EBP) during wound and high-contact Activities of Daily Living (ADL) care for one of 10 residents (R) (R2) requiring EBP. This deficient practice had the potential to increase R2's risk of infections.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled, Abuse Prohibition, the facility failed to effectively address the sexually aggressive behavior of one of four residents (R#364). The facility failed to put effective interventions in place to protect three of four residents (R#17, R#55, R#42) from resident-to-resident sexual abuse. The deficient practice had the potential to affect all 61 residents residing in the facility On 04/14/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 04/14/2022 at 7:46 PM. [...]

Inspectors wroteBased on interview, record review, document review, and review of facility policies titled, Reporting and Investigating Abuse, and Abuse Prohibition - Screening, Hiring and Training Practices, the facility failed to develop and/or implement the protection, reporting, training components of their abuse for three of four (R#17, R#42, R#55) residents reviewed for sexual abuse. On 04/14/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 04/14/2022 at 7:46 PM. The noncompliance related to the immediate jeopardy was identified to have existed on 05/23/2021. The immediate jeopardy was removed on 04/17/2022. The IJ is outlined as follows: [...]

Inspectors wroteBased on interviews, document review, and review of facility policies titled, Reporting and Investigating Abuse, the facility failed to ensure allegations of sexual abuse were reported to the police for three of four [R#17, R#55 R#42,] sampled residents reviewed for sexual abuse. On 04/14/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 04/14/2022 at 7:46 PM. The noncompliance related to the immediate jeopardy was identified to have existed on 05/23/2021. The immediate jeopardy was removed on 04/17/2022. The IJ is outlined as follows: [...]

Inspectors wroteBased on observations, record review, staff and family interviews, and review of facility policies titled, Reporting and Investigating Abuse, the facility failed to ensure allegations of sexual abuse were thoroughly investigated and failed to implement protective measures to prevent further incidences of sexual abuse for three of four (R#17, R#55, R#42) residents reviewed for sexual abuse. On 04/14/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 04/14/2022 at 7:46 PM. The noncompliance related to the immediate jeopardy was identified to have existed on 05/23/2021. The immediate jeopardy was removed on 04/17/2022. [...]

Inspectors wroteBased on observations, interviews, record review, document review, and review of the facility policy titled, Patient's Plan of Care, the facility failed to ensure person-centered, comprehensive care plans were developed to meet the safety and psychological needs of four of 16 (R#364, R#17, R#42 and R#55) whose care plans were reviewed. Specifically, the facility failed to ensure the comprehensive care plan for R#364 addressed the resident's sexually abusive behaviors to prevent further sexual abuse of other facility residents; and the comprehensive care plans for R#17, R#42, and R#55 failed to address protective measures and the necessary care, assessments and monitoring related to having been sexually assaulted by R#364. [...]

Inspectors wroteBased on observations, record review, review of the Facility's Job Title: Administrator and the Facility's Job Title: Director of Nursing Services Administration failed to ensure residents were free from resident-to-resident sexual abuse, failed to develop and implement policies and procedures to prohibit abuse, failed to develop policies and procedures to ensure reasonable suspicion of a crime against any resident was reported to local law enforcement, failed to ensure all alleged incidents of sexual abuse were thoroughly investigated and immediate protective measures were put into place, failed to ensure person-centered, comprehensive care plans were developed to meet the safety and psychological needs. The failed practice had the potential to affect all 61 residents residing in the facility. [...]

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled, Patient's Plan of Care, the facility failed to ensure care plans were revised to include residents' current care needs for one of 26 (R#2) sampled residents whose care plans were reviewed. Specifically, the facility failed to ensure the care plan for toileting was revised after R#2 became more independent with toileting.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two residents (R#44), reviewed for activities of daily living (ADLs), received necessary services to maintain grooming and personal hygiene. Specifically, the facility failed to provide nail care for R#44.

Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled, Restorative the facility failed to ensure one of 14 (R#34), residents reviewed who required a restorative nursing program, received restorative nursing services in accordance with R#34's Nursing Restorative Care Program.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled, Skilled Inpatient Services - Accident Investigation Guidelines, the facility failed to conduct comprehensive investigations and root cause analyses to determine the cause of falls to prevent future falls for two of five sampled residents [R#44 and R#37] reviewed for accidents.

Inspectors wroteBased on record review, observations, interviews, and review of facility procedural guidelines titled, Pharmacy Services Medication Administration-General and Pharmacy Services Discontinued Medications, the facility failed to ensure a medication error rate less than 5%. There were three errors out of 36 opportunities, resulting in a medication error rate of 8.33% involving (R#4 and R#35). Specifically, the facility failed to ensure R#4 received an ordered antibiotic ointment for the eyes; and failed to ensure that R#35 was not administered a discontinued beta-blocker and was administered the correct dose of a supplement.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Description of Facility Services the facility failed to ensure one of one residents (R#36) sampled for dental care received dental care as needed. Specifically, the facility failed to ensure a referral or examination occurred for R#36 to address ill-fitting dentures.