Country Gardens Health and Rehabilitation

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Country Gardens Health and Rehabilitation? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Country Gardens Health and Rehabilitation

Country Gardens Health and Rehabilitation is a for profit, 86-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Swansea, Warren RI, Barrington RI, Rehoboth, Somerset, Seekonk, Fall River, Bristol RI, East Providence RI, Tiverton, RI, and the other towns in and surrounding Bristol County, Massachusetts.

Country Gardens Health and Rehabilitation
2045 Grand Army of the Republic Hwy,
Swansea, MA 02777

Phone: 508-379-9700
Website: http://www.countrygardens-health.com/

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2017, Country Gardens Health and Rehabilitation in Swansea, Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Country Gardens Health and Rehabilitation

The Federal Government fined Country Gardens Health and Rehabilitation $21,938 on June 18th 2015, $8,076 on February 13th 2017, and $56,652 on April 26th 2017, for health and safety violations.

Fines and Penalties

Our Nursing Home Injury Attorneys inspected government records and discovered Country Gardens Health and Rehabilitation committed the following offenses:

Failed to give the resident's representative the ability to exercise the resident's rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the Facility failed to ensure that for 2 Residents (#12 and #13), who had not been deemed unable to make healthcare decisions by a physician, be able to make their own health care decisions, of a total sample of 16 Residents.

Findings include:

1. Resident #12 was admitted to the Facility in 3/2017 and had [DIAGNOSES REDACTED]. Review of Resident #12’s admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/4/17, indicated that the Resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) indicating that he/she was cognitively intact. Review of the clinical record on 4/25/17 indicated that Resident #12 was deemed able to make his/her own medical decisions. Review of Resident #12’s clinical record indicated that the Resident’s Health Care Proxy (HCP) was not activated by the physician. Review of Resident #12’s clinical record indicated that the Resident’s daughter signed the Authorization to use and/or Disclose Health Information dated 4/5/17 and signed the Request for Service from Health Drive dated 4/5/17. The Surveyor interviewed Resident #12 at 1:15 P.M. on 4/26/17. The Resident said he/she did not ask his/her daughter to sign forms for him/her. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 4/25/17. The DON said she was made aware by the nursing staff that Resident #12’s daughter had signed forms and the Resident did not have an activated Health Care Proxy.

2. Resident #13 was admitted to the Facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the clinical record on 4/25/17 indicated that Resident #13 was deemed able to make his/her own medical decisions. Review of the nursing progress notes dated 04/10/17 indicated that Resident #13 was alert and oriented to person, place and time. Review of Resident #13’s clinical record indicated that the Resident’s daughter signed a form dated 4/10/17, that in the event of cardiac or respiratory arrest the Resident should be resuscitated. The daughter also signed the Resident’s consent to treat form. The Surveyor interviewed Resident #13 at 1:30 P.M. on 4/26/17. The Resident said he/she did not ask his/her daughter to sign the forms for him/her. The Resident said advanced directives were not reviewed with him/her. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 4/25/17. The DON said she was made aware by nursing staff that Resident #13’s daughter signed the Resident’s forms and the Resident did not have an activated HCP.

Failed to tell the resident completely about his or her health status, care and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the Facility failed to ensure that for 1 Resident (#4), who had not been deemed unable to make healthcare decisions by a physician, make their own health care decisions in a total sample of 16 Residents.

Findings include:

Resident #4 was admitted to the Facility in 6/2016 with [DIAGNOSES REDACTED]. Review of Resident #4’s clinical record indicated that the Resident’s daughter signed an advanced directive form dated 6/17/16 indicating that he/she was a Do Not Resuscitate (DNR), was a Do Not Intubate (DNI), and No artificial nutrition. In addition, the daughter signed the consent to treatment dated 6/17/16.

Review of the clinical record on 4/25/17 indicated that Resident #4’s Health Care Proxy (HCP) was activated by a physician on 09/23/16. The Surveyor was unable to interview Resident #4 because the Resident was cognitively impaired. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 4/25/17. The DON said she was made aware by nursing staff that Resident #4’s Health Care Proxy was not activated by the physician when the Resident’s daughter signed his/her forms.

Failed to let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and Resident interview, the Facility failed to ensure information was provided during the process of choosing to either formulate and/or not formulate advanced directives that would ensure the Resident’s decisions were accurately reflected in the medical record, for 1 Resident’s (#12) out of a total sample of 16 residents.

Findings include:

For Resident #12 the Facility failed to accurately reflect the Resident’s wishes for advance directives. Resident #12 was admitted to the Facility in 3/2017 and had [DIAGNOSES REDACTED]. Review of Resident #12’s admission Minimum Data Set (MDS) assessment with an assessment reference date of 4/4/17, indicated that the Resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS). This indicated that he/she was cognitively intact. Review of Resident #12’s clinical record indicated that the Resident signed a form dated 3/29/17, indicating that he/she wished to be a full code in the event of a cardiopulmonary arrest. The form was signed by the physician and dated 3/29/17.

Review of Resident #12’s clinical record indicated the Resident’s daughter signed a form the day after, dated 3/30/17 indicating that the Resident was a Do Not Resuscitate (DNR). Review of Resident #12’s clinical record indicated that the Resident’s Health Care Proxy (HCP) was not activated by the physician. The Surveyor interviewed Resident #12 at 1:15 P.M. on 4/26/17. The Resident said he/she wanted to remain a full code until today (4/26/17). Resident #12 said he/she did not ask his/her daughter to change his/her code status or sign a new form. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 4/25/17. The DON said she was made aware by the nursing staff that Resident #12’s code status was changed the day after Resident #12 signed to be a full code, by the Resident’s daughter and the Resident did not have an activated HCP.

Failed to keep clinical records for The length of time that is required by State law; or Five years from the date of discharge when no requirement in State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility staff failed to retain medical records for one sampled Resident (#6) in a total sample of 16 Residents.

 

Findings include:

Resident #6 was admitted to the Facility in 10/2016 with [DIAGNOSES REDACTED]. Review of assessments for Resident #6, provided by Unit Manager (UM) #2 on 04/20/17 indicated an Elopement risk data collection and assessment was conducted on 10/18/16 and reviewed on 01/10/17 and 04/11/17 by Nurse #1. The results of the assessment indicated Resident #6 was at risk for elopement and to implement plan of care.

Review of assessments for Resident #6, provided by the Administrator on 04/21/17 indicated an Elopement risk data collection and assessment was conducted, and incorrectly dated, 10/18/17 by UM #2 and reviewed on 01/18/17 by the Director of Nursing (DON). Nurse #1 was interviewed on 04/21/17 at 2:45 P.M. Nurse #1 said she was was reviewing elopement assessments for an audit on 04/11/17 and could not find an initial elopement assessment for Resident #6. Nurse #1 said that on 04/11/17 she completed an elopement assessment and back dated it to the day after admission and dated that it was reviewed on 01/10/17. Nurse #1 said she felt she knew Resident #6 when he/she was admitted six months prior. Nurse #1 confirmed she was not a regularly scheduled nurse on the unit on which Resident #6 resided previously.

UM #2 was interviewed on 04/21/17 at 2:30 P.M. UM #2 said she was handed the assessment form by UM #1, the day prior and was told she did not put a date on the form and that she mistakenly wrote in 10/18/17, instead of 10/18/16. UM #2 said she had originally completed some admission assessments for Resident #6 and she wrote the date she thought she had done the assessment. UM #2 said she also signed the form on 04/20/17. The Administrator and DON were interviewed on 04/21/17 at 3:40 P.M. The Administrator said Nurse #1 had not worked on the unit on which Resident #6 resided, Nurse #1 was not instructed to complete an elopement assessment audit or to recreate documents. The Administrator said she interviewed Nurse #1 who admitted she threw away the original elopement assessment as she did not feel it was accurate and recreated an assessment. The original elopement assessment, completed as part of the admission assessments, for Resident #6 was unable to be located by Facility staff.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of four sampled residents (Resident #3), the Facility failed to ensure that four allegations of abuse was immediately reported to the Administrator or their designee. Although Certified Nurse Aide (CNA) #3 documented on Resident #3’s Activities of Daily Living (ADL) flow sheets on four separate occasions, over a period of three months, that Resident #3 said CNA #3 hurt him/her during care, these allegations were not reported to the Administrator until 3/29/17, 11 days after CNA #3’s last entry on the ADL flow sheets.

Findings include:

The Facility’s Policy and Procedure on Abuse Prevention, dated March 2016, indicated all staff are to report any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property immediately to the Administrator, Director of Nurses or Shift Supervisor. Resident #3’s most recent Minimum Data Set (MDS) Assessment Form, completed 2/28/17, indicated Resident #3 had [DIAGNOSES REDACTED]. Resident #3’s Care Plan for Pain Management, dated 2/28/17, indicated Resident #3 was at risk for alteration in comfort related to impaired mobility and contractures. The Surveyor interviewed Resident #3 at 9:10 A.M., on 7/6/17. Resident #3 had no recall of any incidents and did not verbalize any concerns regarding the care provided by staff. Review of the Facility Internal Investigation, dated 3/29/17, indicated on 3/29/17, following a chart audit completed by the nursing department, the Administrator was informed that CNA #3 documented on Resident #3’s ADL flow sheets on four separate occasions, over a period of three months, that Resident #3 said CNA #3 hurt him/her during care. The investigation indicated the allegations were not reported to the Administrator until 3/29/17, 11 days after CNA #3’s last entry on the ADL flow sheets. The investigation indicated a full skin assessment was completed and no injuries, bruises or marks were identified on Resident #3. The investigation indicated Resident #3 told the Administrator that CNA #3 intentionally mistreated him/her during every shift as she provided care and requested CNA #3 not provide care any longer.

The Surveyor interviewed CNA #3 at 4:00 P.M., on 7/10/17. CNA #3 said Resident #3 often called out during care, called CNA #3 derogatory names and accused CNA #3 of hurting him/her as she provided care. CNA #3 said she was told by nursing staff to document such incidents on the resident ADL flow sheets and report the incidents to a nurse. CNA #3 said she documented as instructed by the nursing department and reported the alleged incidents to a nurse. CNA #3 said she could not recall who she reported the incidents to, but did as she was told. CNA #3 said she believed Resident #3 did not like people of other ethnicities so she always provided care with another staff person. CNA #3 said she never hurt Resident #3 and denied the allegations.

The Surveyor interviewed the Administrator at 8:10 A.M., and throughout the day on 6/30/17 and 7/6/17. The Administrator said it was Facility policy for all staff to immediately report all allegations of abuse, and accused staff were to be immediately suspended pending the internal investigation. The Administrator said although CNA #3 documented on Resident #3’s ADL flow sheets on four separate occasions, over a period of three months that Resident #3 complained CNA #3 hurt him/her during care, these allegations were not reported to the Administrator until 3/29/17, 11 days after CNA #3’s last entry on the ADL flow sheets, which was not consistent with Facility policy. The Administrator said once the allegations became known to management on 3/29/17, an investigation was immediately initiated and CNA #3 was suspended pending the outcome of the the Facility’s investigation.

On 7/6/17, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by:
A) The Administrator said CNA #3 was immediately suspended pending the outcome of the Facility investigation.
B) The Administrator said any and all CNAs that were identified during the Facility internal investigation for failure to follow the Facility Policy and Procedure for Abuse Prevention were suspended.
C) Facility wide skin assessments and interviews were completed on 3/29/17 by the Administrator and the Director of Nurses on all residents with a brief interview mental status (BIMS) score of 10 or less, with a follow up call made to the listed next of kin to assure there were no other resident care concerns.
D) Facility wide interviews were completed on 3/29/17 by the Administrator and Director of Nurses with all residents with a BIMS of 10 or higher to assure there were no other resident care concerns.
E) A Facility wide mandatory in-service program with all staff was initiated on 3/29/17 and completed on 3/31/17 regarding the Facility’s Abuse Prevention Policy and Procedure, including timely reporting.
F) A Facility wide mandatory in-service program with all CNAs was completed on 3/30/17 regarding documentation of ADL flow sheets.
G) Audits of all resident ADL flow sheets to be completed once weekly for four weeks.
H) Facility wide mandatory in-service education to be competed once weekly for four weeks with staff to complete post test evaluation for education programs.
I) The Administrator was responsible to monitor on-going audits and present the findings to the Quality Assurance Improvement Committee.
J) The Quality Assurance Improvement Committee met on 3/30/17 and will continue to review findings with additional measures to be implemented as needed. The Facility was placed in past non compliance as of 3/31/17.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for 2 of 3 sampled residents (Resident #1 and #2), the Facility failed to ensure that a thorough investigation was conducted into surrounding events involving two unwitnessed falls resulting in Resident #1 sustaining a fractured right hip and Resident #2 sustaining a laceration with a nasal fracture, both injuries of unknown origin.

Findings include:

The Facility’s Policy titled Incident Reports indicated the supervisor/unit manager will review reports immediately with employees and obtain statements. The policy further indicates to make copies of past 24 hour staffing to get statements as appropriate ( injuries of unknown origin) and the unit manager must complete an investigation and return the incident report to the ADON/DON. The incident report will be forwarded to the Administrator and DON for final review and signature after the completion of the investigation.

The Facility’s Policy titled How to Conduct an Investigation indicated the facility has processes to enable it to come to a resolution after thoroughly investigating all accidents and incidents by interviewing all potential witnesses, determining what occurred, documenting on the accident/incident follow-up and documenting the results/analysis on the accident/incident final disposition report. Resident #1’s Minimum Data Set (MDS), dated [DATE] indicated, Resident #1 was severely cognitively impaired and required supervision with ambulation and extensive assist with transfers.

An Event/Incident Report, dated 11/24/16 at 1:15 P.M., indicated CNA#2 reported that another resident, name unknown, yelled out that Resident #1 was falling and when CNA#2 turned, Resident #1 was lying on the floor. A witness statement, dated 11/24/16, indicated CNA #2 heard another resident, name unknown, yelling for help and when CNA #2 turned around, she saw Resident #1 on the floor in the day room

A Nurse Progress note, dated 11/24/16, indicated Resident #1 sustained a fall witnessed by an unidentified resident. Resident #1’s fall was unwitnessed by facility staff. Resident #1 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed CNA #2 at 2:27 P.M. on 2/13/17. CNA #2 said she was in the day room assisting a resident when she heard another unidentified resident yell out Resident #1 just fell . CNA #2 said she turned around and saw Resident #1 on the floor. CNA #2 said she did not witness Resident #1 fall and informed Nurse #1 that Resident #1 was on the floor. The Surveyor interviewed Nurse #1 at 3:37 P.M. on 2/13/17. Nurse #1 said she did not witness Resident #1 fall, recalls Resident #1 complained of pain and informed Nurse #4 of Resident #1’s pain.

Nurse #4 did not respond to the Surveyor’s requests for interview made by telephone or by letter sent to the address of record at the Facility as of the date of this Statement of Deficiency. The Surveyor interviewed the Director of Nurses (DON) at 5:10 P.M. on 2/13/17 and throughout the day on 2/14/17 and 2/21/17. The DON said Resident #1’s incident report is an investigation and the Facility does not do any further investigation or obtain further witness statements after every incident or fall as long as an intervention is put into place. This is inconsistent with Facility Policy.

Resident #2’s Minimum Data Set (MDS), dated [DATE] indicated, Resident #2 was severely cognitively impaired and required supervision with ambulation and transfers. An Event/Incident Report, dated 1/23/17 at 2:30 A.M. indicated Nurse #2 was called into Resident #2’s room by staff member. Resident #2 was noted to have a bloody nose, laceration, bruise to bridge of his/her nose, complained of pain and stated he/she fell . A Nurse Progress note, dated 1/23/17, indicated Resident #2 was walking out of his/her room with a bloody nose, laceration, bruise to bridge of his/her nose, complaining pain and stated he/she fell . This was inconsistent with Event/Incident Report. Resident #2 was transferred to the hospital where he/she was diagnosed with [REDACTED]. The Surveyor interviewed Nurse #2 at 9:39 A.M. on 2/21/17. Nurse #2 said on 1/23/17 on the 11 P.M. -7 A.M. shift, CNA’s were doing rounds and called her into Resident #2’s room. Nurse #2 said she saw Resident #2 sitting on the floor with a bloody nose and Resident #2 stated to Nurse #2 he/she fell . Nurse #2 said the unit manager or DON is responsible for doing an investigation after a fall.

The Surveyor interviewed the Director of Nurses (DON) at 5:10 P.M. on 2/13/17 and throughout the day on 2/14/17 and 2/21/17. The DON said the facility does not have a policy on injuries of unknown origin and does not do an investigation or obtain witness statements after every incident or fall. The DON said facility documentation is sketchy and lacking and an investigation and witness statements should have been completed for Resident #2’s injury of unknown origin. The DON said she is responsible for completing the investigation. This is inconsistent with Facility Policy. The Facility was unable to provide supporting documentation that a thorough investigation was completed in accordance with Facility policy, into the events surrounding how Resident #1 fell sustaining a fractured right hip and Resident #2’s injury of unknown origin who was found on floor with laceration on nose resulting in a nasal fracture. Resident #1 and Resident #2 were transferred to the hospital.

Country Gardens Health and Rehabilitation, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Country Gardens Health and Rehabilitation

Health Inspection Report for Country Gardens Health and Rehabilitation – 04/26/2017

Complaint Inspection Country Gardens Health and Rehabilitation 07/06/2017

Complaint Inspection Country Gardens Health and Rehabilitation 02/13/2017

Page Last Updated: February 20, 2018

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