Worcester Rehabilitation & Health Care Center

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an unwitnessed fall and an episode of emesis (vomiting) during the 11:00 P.M. to 07:00 A.M. shift, and then experienced a decline in condition, the Facility failed to ensure nursing notified the Provider in a timely manner, as required.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one Resident (#133) out of a total sample of 27 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #133, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures that can be taken when a person's heart stops or they fail to breathe on their own), psychotropic medication, vaccination education, and ancillary services that could be provided while at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate access to the call light for one Resident (#88) out of a total sample size of 27 residents. Specifically, for Resident #88, the facility staff failed to place the Resident's call light within his/her reach, putting Resident #88 at risk of falls, and being unable to request staff assistance when needed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that assistive devices to maintain vision were acquired for one Resident (#118) out of a total sample of 27 residents. Specifically, for Resident #118, the facility failed to ensure that a prescription for necessary glasses was filled, as recommended by the Optometrist (Eye Doctor).

Inspectors wroteBased on record review, and interviews, the facility failed to ensure that one Resident (#103) out of a total sample of 27 residents, with limited range of motion (ROM) received appropriate care and services to maintain and/or improve their mobility function. Specifically, the facility staff failed to implement a functional mobility program to have staff walk with Resident #103 as recommended by PT (Physical Therapy) upon discharge from skilled services, which resulted in an avoidable reduction in ROM and mobility for the Resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide peripherally inserted central catheter (PICC: flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]) care and services in accordance with professional standards of practice and plan of care for one Resident (#137) of two applicable residents receiving IV treatment via PICC, out of a total sample of 27 residents. Specifically, for Resident #137, the facility staff failed to measure the external length of the PICC weekly, as ordered by the Physician to prevent the risk of inadvertent PICC migration and catheter related complications.

Inspectors wroteBased on record review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#30) out of a total sample of 27 residents. Specifically, the facility failed to ensure that Resident #30 received follow-up Behavioral Health Services after recommendations for continued psychiatric follow-up visits were made by the Provider for a Resident with known mental illness, who demonstrated behaviors, was prescribed psychotropic medications, and who required emergency mental health evaluation for suicidal ideation (SI).

Inspectors wroteBased on record review, and interviews, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for one Unit (5th Floor) out of four units reviewed. Specifically, for the 5th Floor Unit, the facility staff failed to maintain accurate documentation in the Controlled Substance Register (Narcotic Book), relative to the recording of prescription numbers and receipt dates being recorded on the individual pages when a new controlled medication was entered into the Register or the information for a medication was transferred from one page to another.

Inspectors wroteBased on interviews, and record reviews, the facility failed to maintain a complete and accurate clinical record for one Resident (#133) out of a total sample of 27 residents. Specifically, for Resident #133, the facility failed to accurately document the daily total amount of administered enteral feeding.

Inspectors wroteBased on observations, and interviews, the facility failed to maintain appropriate hygiene practices while serving meals in the dining room, on one Unit (1st Floor) out of four Units observed. Specifically, the facility failed to ensure that staff distributing food during the lunch meal on the 1st Floor dining room performed appropriate hand hygiene during the meal service to prevent contamination and the spread of foodborne illnesses.

Inspectors wroteBased on observations (which included taking photographs), interviews and records reviewed, for four of four resident units, the facility failed to ensure it provided a safe, clean, comfortable and homelike environment for it's residents, when during the course of the survey observations conducted in common areas, resident rooms, and resident care areas, there was obvious signs of various stages of disrepair, aging and unclean conditions, on flooring, walls, ceilings and windows, all of which were in areas accessed and utilized by residents in their daily lives, and were either unsafe, in need of immediate repair and/or created potentially hazardous conditions, none of which supported that a homelike environment was being provided for facility residents.

Inspectors wroteBased on observations and interviews, for four out of four nursing units Nourishment Kitchens and in the facility's main kitchen, specifically the dish room, the Facility failed to ensured they maintained a sanitary environment related to food storage/preparation, which placed all residents at risk for food-borne illness.

Inspectors wroteBased on records reviewed, interviews, and observations, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility.

Inspectors wroteBased on observations and interviews for four out of four resident units, the Facility failed to ensure they provided a functional Resident Call/Communication System which relayed to the cell directly to staff or a centralized staff work area, that allowed residents residing on the units, to call for staff assistance.

Inspectors wroteBased on observations, records reviewed and interviews, the Facility failed to ensure they maintained an effective pest control program, when from the end of May 2024 to the beginning of August 2024, despite having a known active, ongoing infestation of mice and German Cockroaches (one of the most stubborn and difficult species to eliminate) in several resident care areas of the Facility, Pest Control Service visits and treatments were not conducted at the Facility during that time.

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure that resident grievances related to services provided by the Dietary Department, including reports of cold food, were addressed and resolved by the Facility in a timely manner, when review of the last two months of Resident Council Meeting minutes, and interviews with residents, indicated there were still ongoing and unresolved resident concerns.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for developing Diabetes-related foot complications, with physician's orders for diabetic foot care, the Facility failed to ensure Resident #1 received proper care and treatment to maintain good foot health.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), who was assessed to be at risk for nutritional decline secondary to wound healing needs, anemia, multiple food allergies, multiple food preferences, and who had planned weight loss goals, the Facility failed to ensure Resident #2's nutritional status including body weight, were accurately assessed and monitored appropriately by nursing and per facility policy, as a result Resident #2 experienced an undesired weight gain in three months.

Inspectors wroteBased on observations and interview, for one of four resident units (Unit 3) the Facility failed to ensure the handrail in the corridor between the Nurse's Station and the Nourishment Kitchen, was secured to the wall.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure nursing notified Resident #1's Physician when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her scheduled doses for five days (missing a total of 15 doses).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered his/her narcotic medication multiple days in a row (missing a total of 15 doses), which placed him/her at increased risks for adverse side effects as a result of abruptly stopping the medication.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure they maintained a complete and accurate medical record when nursing documented the narcotic medication was administered, despite the medication being unavailable at the Facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for the facility residents on four Units (Unit Two, Unit Three, Unit Four, and Unit Five) out of four units observed. Specifically, the facility staff failed to repair, replace and clean: 1. On Unit Two: holes in the walls, soiled curtains, stained ceiling tiles, and a leaky bathroom sink. 2. On Unit Three: missing mirror, stained and damaged ceilings, damaged walls, loose toilets and soiled curtains. 3. On Unit Four: broken closet door, urine odor, and a damaged wall. 4. On Unit Five: leaking bath tub faucet.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were coded accurately for one Resident (#135) out of three closed record residents and for four Residents (#3, #23, #32, and #67) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that an MDS Assessment: 1. For Resident #135, was accurately coded relative to the Resident receiving Hospice (End of Life) services. 2. For Resident #3, was accurately coded relative to the Resident having a Significant Mental Illness (SMI) per a Preadmission Screening and Resident Review (PASRR) Level II (an evaluation that confirms whether an individual has a SMI or Intellectual/Developmental Disability). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the plan of care for one Resident (#132) out of a total sample of 26 residents. Specifically, the facility staff failed to monitor fluid intake and output for Resident #132 as ordered.

Inspectors wroteBased on interview, policy and record review, the facility failed to maintain professional standards of practice related to psychiatric services for one Resident (#28) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that recommendations made by the Psychiatric Nurse Practitioner (NP) for medication changes were reviewed by Resident #28's Attending Physician resulting in delayed management of anxiety and pain symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to ensure activities of daily living (ADLs) were maintained for two Residents (#109 and #14) who required assistance for self-care out of a total sample of 26 residents. Specifically, the facility staff failed to ensure: 1. For Resident #109, that staff assisted the Resident with maintaining the cleanliness and length of his/her fingernails. 2. For Resident #14, that staff assisted with grooming and ensured the Resident was free from facial hair per personal and Resident Representative preference and Physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent a decrease in range of motion (ROM) for one Resident (#15) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that a resting hand splint (a device to properly position and protect hand joints) to prevent hand contracture (a condition of shortening and hardening of muscle, tendons or other tissue often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to provide care and services in accordance with professional standards of practice for two Residents (#18 and #77) out of a total sample of 26 residents, who required vascular access devices (devices that provide access to the veins for the delivery of medications or fluids). Specifically, the facility staff failed to: 1) For Resident #18, obtain Physician orders for the care and maintenance of a midline catheter (a flexible tube inserted through a peripheral vein above the elbow that ends just below the axilla [armpit]). 2) For Resident #77, ensure that the external length of a Peripherally Inserted Central Catheter (PICC: [...]

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 (#75) out of a total sample of 26 residents. Specifically, the facility staff failed to ensure that Resident #75 was administered the appropriate liter per minute (LPM- the amount of supplemental Oxygen someone received through an oxygen delivery device) of Oxygen as ordered by the Physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#3) out of a total sample of 26 residents, who had a history of Post Traumatic Stress Disorder (PTSD - a disorder that develops when someone has experienced a traumatic event) had a care plan developed that included the Resident's identified PTSD triggers (certain stimuli that bring back strong memories from a traumatic event these can include but are not limited to sounds, smells, physical actions, and thoughts, that can cause an adverse reaction). Specifically, the facility staff failed to identify physical abuse as a trigger for Resident #3, causing retraumatization when a male staff member put his hand on the Resident's shoulder.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to provide appropriate medical care and supervision for one Resident (#77) out of a total sample of 26 residents. Specifically, the facility staff failed to obtain a Physician order for the continued treatment of a left elbow surgical wound for Resident #77, after removal of a wound therapy device.

Inspectors wroteBased on record review and interview, the facility failed to monitor the side effects and adverse reactions of psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior and includes antipsychotic, antianxiety, antidepressant, and hypnotic medications) medications for three Residents (#67, #97 and #129) out of a total sample of 26 residents. Specifically, the facility staff failed to monitor for adverse consequences and improved behaviors: 1. For Resident #67, who was ordered for, and was being administered Seroquel, Depakote, Remeron and Gabapentin (psychotropic) medications. 2. For Resident #97, who was ordered for, and was being administered Zyprexa, Trazodone, and Ativan (psychotropic) medications. 3. For Resident #129, who was ordered for, and was being administered Invega (psychotropic) medication.

Inspectors wroteBased on interview, record and policy review, the facility failed to offer the Pneumococcal Vaccination as recommended to one Resident (#28) out of five applicable residents, in a total sample of 26 residents. Specifically, for Resident #28, the facility failed to ensure that Resident #28 was offered the Pneumococcal Conjugate Vaccine (PCV- a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia.

Inspectors wroteBased on observation and interview, the facility failed to maintain a functioning call system that would allow residents to directly contact caregivers for one Resident (#119) out of a total sample of 26 residents, and in five resident rooms on Unit Two. Specifically, 1. The facility failed to have functioning call bells in five resident rooms (room [ROOM NUMBER] - room [ROOM NUMBER]) on Unit Two when the communication system that relayed calls directly to staff or to a centralized work area was identified as not working. 2. The facility staff failed to provide Resident #119 with a call bell as an alternative means to call for assistance when the call system in the Resident's room was not working.

Inspectors wroteBased on records reviewed, interviews and observations of two of two sampled resident care units (Unit 3 and Unit 4), the Facility failed to ensure they provided residents a safe, clean, comfortable and homelike environment, when during the survey, there were signs of physical disrepair which included brown stained ceiling tiles, soiled window and privacy curtains, and rodent droppings.

Inspectors wroteBased on records reviewed and interviews, the Facility failed to ensure that resident grievances related to care and services provided by the nursing staff were addressed and resolved by the Facility in a timely manner, when review of the last three monthly Resident Council Meeting minutes indicated there were ongoing and unresolved resident concerns.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had limited mobility, and preferred to stay in bed, the Facility failed to ensure he/she was provided with adequate preventative measures to maintain his/her safety in an effort to prevent incidents/accidents resulting in serious injury, when he/she sustained burns from food that had been reheated in the microwave by staff. On 09/01/23, Resident #1 asked a staff member to reheat his/her soup, after the staff member reheated the soup in the microwave, she did not check the temperature of the soup, per facility guidelines, before bringing it back to Resident #1. [...]

Inspectors wroteBased on records reviewed, interviews and observations for two of two sampled nursing units (Unit 2 and Unit 4), the Facility failed to ensure they provided residents a safe, clean, comfortable, and homelike environment, when during the survey, there were signs of physical disrepair which included uncovered electrical outlets, rodent droppings, and bugs in common areas.

Inspectors wroteBased on records reviewed, interviews, and observations, for two of three sampled residents (Resident #1 and #3), the Facility failed to ensure medications were kept locked or under direct observation of a nurse, when on 09/27/23 the Surveyor, observed 1) an Albuterol inhaler on the bedside table and a container of Silver Sulfadiazine cream on the nightstand in Resident #1's room and 2) a Flonase nasal inhaler and an Albuterol inhaler on Resident #3's side table. At the time of the observation, there were no facility nurses in either Resident #1 or Resident #3's room, therefore the medications were left unattended and unsecured. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided evidence that the timeframe for use of antipsychotic medication on an as needed (PRN) basis was limited to 14 days, as required, for one Resident (#49) out of 27 total sampled residents. Specifically, the facility failed to ensure its staff provided evidence that the Resident was re-evaluated every 14 days and a new order entered for PRN use of Haloperidol (antipsychotic medication) and Quetiapine Fumarate (antipsychotic medication) when the medications were being administered to the Resident.

Inspectors wroteBased on observation and interview the facility failed to ensure its staff stored medications and biologicals properly. Specifically, the facility failed to ensure its staff: 1) Secured medications located in a facility conference room. 2)Stored schedule II (considered highly addictive with a dangerous potential for abuse) controlled medications in a separately locked compartment in one out of four medication rooms and two out of eight medication carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff maintained dignity and respect for one Resident (#128) out of a total sample of 27 residents. Specifically, staff laughing at concerns voiced by the Resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff immediately notified the Physician/Non-Physician Practitioner (NPP) of the need to discontinue an existing form of treatment and commence a new form of treatment for one Resident (#129) out of 27 total residents sampled. Specifically, the facility failed to ensure its staff notified Resident #129's Physician/NPP of the Wound Physician's recommendation to alter the treatment for a stage four (full thickness skin and tissue loss) pressure wound on the Resident's right heel.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that its staff provided activities of daily living (ADL) care for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility did not follow the Physician's orders as documented in the Resident record for bi-weekly nail trimming.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that its staff provided quality of care according to professional standards of practice for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility failed to identify and assess changes in the Resident's skin condition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff involved the Physician/Non-Physician Practitioner (NPP) in evaluating and managing complications of an enteral feeding tube (surgically placed device that delivers nutrition into the digestive system) for one Resident (#132) reviewed, of three residents with enteral feeding tubes, out of a total sample of 27 residents. Specifically, the facility failed to ensure its staff: a) Consulted the Physician/NPP or obtained orders from the Physician/NPP for declogging the Resident's enteral feeding tube prior to using a manual device to declog the tube. b) Discarded the disposable, one time use manual declogging device after staff used the device to declog the Resident's enteral feeding tube, and c) Documented enteral feeding tube complications and interventions in the Resident's medical record.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided evidence of Nurse competencies relative to managing complications for residents with enteral feeding tubes. Specifically, the facility failed to ensure its staff provided evidence that competencies had been completed for Nurses to use the Quick Clear Wand Enteral Feeding Tube Clog Remover to declog one Resident's (#132) enteral feeding tube, out of three residents with enteral feeding tubes, out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff adhered to food storage and sanitation requirements in three out of four nourishment kitchens.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff monitored two Residents (#44 and #61) for signs and symptoms of COVID-19 daily, out of three sampled residents, to prevent the spread of infection.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff issued transfer notice of hospitalizations to Resident/ Resident Representative for one Resident (#123), out of a total of 27 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff issued a bed hold policy to Resident/ Resident Representative related to hospitalization for one Resident (#123), out of a total of 27 sampled residents.