Woburn Rehabilitation and Nursing Center

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a dignified existence and self determination. Specifically, the facility failed to: 1. Ensure staff did not utilize resident rooms for personal storage for one Resident (#32) out of a total of 29 sampled residents. 2. Attempt to accommodate one Resident (#16)'s, who is his/her own person, desire to attend the senior center, out of a total of 29 sampled Residents. 3. Provide a dignified dining experience in one unit dining room.

Inspectors wroteBased on record review and interviews, the facility failed to investigate allegations of potential abuse for six Residents (#35, #39, #253, #254, #255, and #256) out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews, and record review for two Residents (#72 and #37) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of two nurses observed made 13 errors out of 25 opportunities resulting in a medication error rate of 56%. Specifically, 1.) Nurse #2 attempted to administer 13 medications to the incorrect Resident (#72), which were meant for Resident #37. 2.) Nurse #2 administered the incorrect dose of aspirin to Resident #37.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1.) The facility failed to ensure medications were stored in secured areas and not left unsecured in residents' rooms. 2.) The facility failed to properly secure treatment carts on two of four units. 3.) The facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in two out of four medication carts observed. Review of the facility policy titled 'Medication Storage', dated as reviewed September 2024, indicated: - It is the policy of this facility to ensure all medications housed on our premises will be stored according to manufacturer's recommendations. - All drugs and biologicals will be stored in locked compartments. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide meals at an appetizing, palatable, and safe temperature.

Inspectors wroteBased on observation and interview, the facility failed to follow and maintain foodservice sanitation practices. Specifically, the facility failed to ensure there were thermometers in two refrigerators and failed to accurately record temperatures of the service line, failed to label and date dry products in the kitchen, and failed to ensure there is safe and properly working equipment in the kitchen.

Inspectors wroteBased on review of the grievance log, resident group response and interviews, the facility 1) failed to ensure residents of the facility were aware of the grievance process, had access to grievance forms and 2) failed to resolve a grievance for one Resident (#35) out of a total sample of 29 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement baseline care plans within 48 hours from admission to the facility for one Resident (#360) out of a total sample of 29 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for one Resident (#4) out of a total sample of 29 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to 1) provide edema management for one Resident (#39) and 2) failed to identify a new skin wound on Resident (#360) left calf and document it on a skin assessment, out of a total sample 29 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to address documented significant weight losses for two Residents (#30 and #12) out of a total of 29 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health services for one Resident (#16) out of a total sample of 29 residents. Specifically, Resident #16 verbalized he/she was not happy and had an increased Patient Health Questionnaire (PHQ-9) score, indicating worsening mood.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one Resident (#72) was free from significant medication errors, out of a total sample of 29 residents. Specifically, Nurse #2 attempted to administer medications to the incorrect Resident (#72), including medications that the Resident was allergic to and medications that could jeopardize his or her health and safety.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide dental services for one Resident (#8) out of a total sample of 29 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide the appropriate diet texture for one Resident (#91) out of a total sample of 29 residents.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical device, person is placed in a specialized sling for transfer from one surface to another) for all transfers, the Facility failed to ensure staff maintained his/her safety, when on 9/09/24 during a transfer using the Hoyer lift, the sling was not properly attached to the Hoyer lift by the Certified Nurse Aides (CNAs) performing the transfer, Resident #1 fell from the lift sling to the floor, was noted to be bleeding from his/her head, was transferred to the Hospital Emergency Department (ED), where he/she was diagnosed with multiple injuries including a closed head injury, scalp laceration, fractures to his/her left leg, and was admitted for treatment.

Inspectors wroteBased on records reviewed and interviews for five of ten sampled residents' (Resident #1, #2, #3, #4, and #5) who were all assessed as being a high risk for developing a pressure injury or had an existing pressure injury upon admission, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice related to timely follow up on recommendations, regarding preventative skin care, and obtaining medication and/or treatment orders.

Inspectors wroteBased on records reviewed and interviews for five of ten sampled residents (Resident #1,#2, #3, #4, and #5), who all required physical assistance of one to two staff members with Activities of Daily Living (ADL) and positioning, and (Resident #3, who also required new treatment orders for newly diagnosed pressure injury) the facility failed to ensure they maintained complete and accurate medical records, related to Certified Nurse Aide (CNA) ADL Flow Sheets and Positioning Sheets and when daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets often left blank and for Resident #3, although nursing noted treatments were in place for his/her buttock/coccyx wound, there were no physician's orders on his/her Treatment Administration Record (TAR) in place, or nursing documenation specifically related to wound care for these areas.

Inspectors wroteBased on records reviewed and interviews for one of ten sampled residents (Resident #3), who had experienced a significant change with a decline in medical status, the Facility failed to ensure Resident #3's physician was notified of the change which included the development of a new pressure injury and need for change in treatment.

Inspectors wroteBased on record review and interviews, the facility failed to obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#1) out of a sample of 27 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure that the kitchen was maintained in a clean, sanitary manner.

Inspectors wroteBased on observation, record review and interview, the facility failed to notify the physician of a significant weight loss for one Residents (#1) out of a total of 27 sampled Residents.

Inspectors wroteBased on observations, record reviews, policy reviews and interviews, the facility failed to investigate an injury of unknown origin for 1 Resident (#30) out of a total sample of 27 residents.

Inspectors wroteBased on record review, observation and interview, the facility staff failed to provide the necessary services to ensure one Resident (#33) out of a total sample of 27 Residents, was able to effectively communicate his/her needs.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision for one Resident (#105) out of a total of 27 sampled Residents. Subsequently, Resident #105, who was displaying increased symptoms of agitation, wandering and exit seeking, exited the building and was found outside at approximately 10:00 P.M., on 12/4/23 by CNA #1.

Inspectors wroteBased on observations, record reviews and interview the facility failed to identify and address a significant weight loss in a timely manner for one Resident (#1) out of a total sample of 27 residents.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#205), out of a total sample of 27 residents. Specifically, for Resident #205 the facility failed to obtain arm circumference and PICC line measurements upon admission and weekly as ordered.

Inspectors wroteBased on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to change and clean the oxygen filters for one Resident (#207) out of a total sample 27 residents.

Inspectors wroteBased on observations and interviews and policy review the facility failed to ensure 1. medication carts were locked on 2 of 4 nursing units and 2. failed to ensure medications were stored appropriately in one Resident room.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were stored securely on 3 of 4 units including for 1 Resident (#29) out of a total sample of 25 residents.

Inspectors wroteBased on observation and interview the facility failed to provide a dignified existence for 1 Resident (#70), during a vomiting episode, out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure professional standards of medication administration were adhered to, for one Resident (#63), out of a total 25 sampled residents.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure that oxygen was being administered as ordered by the physician for 1 Resident (#30) out of a total sample of 25 residents.

Inspectors wroteBased on observation and interview the facility failed to implement infection prevention and control practices during medication pass on 1 of 3 units observed.