Baker-Katz Nursing Home

Baker-Katz Nursing Home

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Baker-Katz Nursing Home? 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 Baker-Katz Nursing Home

Baker-Katz Nursing Home is a for profit, 77-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Haverhill, Plaistow NH, North Andover, Atkinson NH, Newton NH, Lawrence, Salem NH, Methuen, Andover, Amesbury, and the other towns in and surrounding Essex County, Massachusetts.

 

Baker-Katz Nursing Home
194 Boardman St,
Haverhill, MA 01830

Phone: (978) 373-5697
Website: http://www.bakerkatznh.com/

CMS Star Quality Rating

Baker-Katz Nursing HomeThe 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 2018, Baker-Katz Nursing Home in Haverhill , Massachusetts received a rating of 2 out of 5 stars.

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

Fines Against Baker-Katz Nursing Home

The Federal Government fined Baker-Katz Nursing Home $38,464 on March 30th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Baker-Katz Nursing Home committed the following offenses:

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 Residents or their responsible person were fully informed in advance, and given information necessary to make health care decisions including the risks and benefits of [MEDICAL CONDITION] medications prior to administration for 3 Residents (#4,#6, #13) in a total sample of 15 residents.

Findings include:

1)For Resident #4 the facility failed to obtain informed consents for the treatment of [REDACTED]. Resident #4 was admitted to the facility in 9/2016. The resident’s [DIAGNOSES REDACTED]. The Initial Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] both identified the resident as being alert and oriented and being his/her own person. Record review indicated there was a 12/22/16 physician’s orders [REDACTED].) 1 tablet by mouth every day at bedtime. In addition, there was a 3/09/17 physician’s orders [REDACTED]. to be given by mouth daily. Further review of the medical record failed to have a consent for either medication. On 3/30/17 at 2:00 P.M., the above information was addressed with the Director of Nursing. She said she would address the issue.

2) For Resident #6 the facility failed to obtain informed consent for the treatment of [REDACTED].) The medical record was reviewed 3/28/17. Resident #6 was admitted to the facility during 10/2015 with [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS) assessment dated [DATE] indicated that Resident #6 had a moderately impaired cognitive status, inattention and disorganized thinking. The MDS also indicated that Resident #6 required extensive assistance from two staff members for transfers, and was totally dependent on one staff member for bathing and dressing. The record indicated that on 10/22/17 Resident #6’s Health Care Proxy was activated, allowing the Health Care Agent, the authority to make decisions related to medical care and treatment. On 3/15/17 the medical record indicated a telephone physician’s orders [REDACTED]. Further review of the medical record failed to indicate a consent for the [MEDICATION NAME] was completed by Resident #6’s Health Care Agent. On 3/29/17 at 3:00 P.M., the Unit Manager (UM) was asked if consent was obtained for the use of [MEDICATION NAME]. The UM looked through the record and said it was not in the chart and she would need to ask about it. The facility Social Worker was present and said any new [MEDICAL CONDITION] medication required informed consent. 3) For Resident #13, the facility failed to have a complete and accurate consent form for the [MEDICAL CONDITION] medication, [MEDICATION NAME] 50 mg. Resident #13 was admitted to the facility during 3/2017 with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #13 had a physician’s orders [REDACTED]., but there was no consent form in the medical record. The facility SW was interviewed on 3/29/17 at 3:00 P.M., and said any new [MEDICAL CONDITION] medication required informed consent.

Failed to keep each resident's personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the Facility failed to assure that personal privacy was maintained for 1 Resident (#7) out of a total sample of 15 residents during a gastrostomy tube (GT) feeding and that privacy regarding prescribed medications and medical records were maintained.

Findings include:

1) Review of Resident #7’s record indicated that he/she was admitted to the Facility in 10/2014 with [DIAGNOSES REDACTED]. The Resident had a contracture of the right hand and an open, flaccid left hand. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 was totally dependent for care and required a hoyer lift for transfers. The Resident was non-ambulatory and required a Broda chair for mobility. Resident #7’s cognition was moderately impaired and he/she was non-verbal. Review of the physician’s orders [REDACTED].#7 received [MEDICATION NAME] 1.5 (a liquid nutritional supplement for use in GT feedings) two cans (237 ml per can) via GT three times a day. On 3/28/17 at 12:50 A.M., Nurse #1 was observed performing a bolus (a method of tube feeding) GT tube feeding for Resident #7. Resident #7’s bare abdomen was exposed to access the GT site. While the GT feeding was infusing, Resident #7’s roommate entered the room to use the bathroom. The room had three beds and the third bed was directly across from the bathroom which all three residents used. Because Nurse #1 had only pulled one curtain, to the left of the bed, and had not closed the curtains to box off the view from all sides, the roommate was able to have full view of Resident #7 receiving the GT feeding. Resident #7’s roommate viewed Resident #7 bare abdomen and GT feeding in process on entering and exiting the restroom. Because Nurse #1 was in the process of infusing the [MEDICATION NAME] solution through the syringe, she was unable to move to close all the curtains required to block view of Resident #7.

2) On 3/28/17 at 4:55 P.M., as Surveyor #1 approached the medication cart where Nurse #2 was continuing to pass medications, Surveyor #1 noted that the medication administration binder was open and the Resident’s medication sheet was open to view without a privacy cover over the paper. The medication cart was unattended and in the hallway where residents, staff and some visitors were walking about in the hallway. Surveyor #1 remained at the medication cart until Nurse #2 returned to the medication cart. Surveyor #1 pointed out the open medication sheet with no privacy cover. Nurse #2 looked at the medication sheet without a privacy cover and replied that she was busy with another resident who needed a pain medication.

3) The facility failed to protect the privacy of medical records. On 3/30/17 at 4:12 P.M., an observation was made of 3 resident medical records on a counter located near the entrance of the facility. It was observed that one of the records was open to a page with personal health information. At 4:16 P. M., on 3/30/17, the Administrator was made aware of the privacy breach and said the clinician who was working with the charts had been called away and should not have left the medical records unattended.

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 documentation review and interview, the facility failed to ensure that an allegation of abuse made by a resident and told to a staff member was reported as an actual allegation of abuse and failed to report this incident in a timely manner.

Findings include:

According to the facility’s Resident Abuse policy last revised 3/20/15: Investigation: When abuse, mistreatment .is reported to or suspected by any employee, the following procedure should be followed:

1. Immediately notify the Charge Nurse on duty. In the absence of the Charge Nurse follow the designated chain of command for report of such incidents ({Director of Nursing, Director of Social Services, Administrator} Notify all.

2. The person who receives notification of the alleged incident will:
a. Notify the appropriate Department Head.
b. Initiate an investigation onto the alleged incident during the shift on which the incident occurred.
c. Interview the resident and/or other residents who may be witnesses.
d. Interview staff member(s) or other person (s) implicated.
e. Ask the implicated person (s) to document his/her knowledge/version of the incident in written narrative that is dated and signed.
f. Interview all other witnesses, staff, family, visitors, etc.
g. Ask all witnesses to document the incident in a written narrative that is dated and signed.
h. Interview all staff on the unit or in the area of the alleged incident for a 24 hour period, when appropriate.
i. If a staff member is implicated in the incident, the employee is sent home after completing a written report of the incident.

Record review indicated resident #5 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Current information identified the resident as being alert and oriented and experiencing mood and psychological issues.

On 3/28/17 at 11:50 A.M., an interview was held with resident #5. The resident reported to Surveyor #3 that he/she had been crying earlier in the morning. At that time,Nursing staff member #1 entered the resident’s room and told him/her to stop his/her crying. Nursing staff person #1 told the resident, oh don’t pull that crying with me, I don’t want to hear it. You’re just trying to get attention. The resident said he/she was not sure of nursing staff member #1’s name.

On 3/28/17 at 1:50 P.M., the resident was re-interviewed. At the time of this interview, nurse staff member #2 was in visiting with the resident in the resident’s room. Nurse staff member #2 left and the resident told surveyor #3 that he/she reported the above comments to Unit Manager (UM) #1 earlier this morning and just reported it to (nursing staff member #2) who just left the room. On 3/28/17 at 2:45 P.M., an interview was held with UM #1. She was asked if the resident had reported anything to her that day and she said the resident had spoken to her earlier in the morning. She said the resident was upset that (nursing staff member #1) had told him/her that he/she was looking for attention because he/she had been crying. She said the resident no longer wanted this person to take care of him/her. UM#1 further said she was aware that Nurse #3 overheard nursing staff member #1 making these remarks loudly to the resident. UM #1 also said a lot of people think the resident overreacts as he/she has psych issues. UM #1 was asked if she reported the incident to anyone and she replied she told the Director of Nursing (DON) just a while earlier. She further said she told the DON that it needed to be addressed. When she was asked if she had taken statements from the resident and the accused employee, she responded that she had not, adding, this is not live note taking here.

On 3/28/17 at 3:00 P.M., an interview was held with the DON and the Administrator. The DON was asked if UM#1 had reported an allegation of abuse made by resident #5 that day. Initially she said UM #1 had not reported anything to her and then recalled that she briefly heard something. She said that someone told her something about the resident being upset about something involving nursing staff member #2 saying something to her while she (the DON) was in the middle of doing something. She could not remember who told her this information and had not followed up on it yet. She did not understand the incident as a reported allegation of abuse made by the resident. The Administrator said he was unaware of the allegation as well. They said they would follow up immediately. On 3/29/17 at 7:15 A.M. an interview was held with the DON and the Administrator. They said a statement was obtained from the accused and she was then sent home. An investigation has now been started. The DON said that UM#1 should have started the investigation immediately, written up a report and informed the Administrator, DON and the Social Worker, which she did not do. The Administrator said that had the process been followed appropriately, the investigation would have been started immediately. He further said that all staff will be re-educated. He added that the resident was interviewed and said that he/she felt safe in the building.

Failed to develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.

Based on record review and interview the facility failed to conduct a complete screening for 1 of 5 newly hired employees (C) prior to the date of hire.

Findings include:

For one newly hired employee (C), the facility failed to conduct a timely check of the appropriate out of state Nurse Aide Registry prior to employment as required. According to the facility’s Resident Abuse policy dated as revised 3/20/15: Screening of employees:

1. Criminal background investigation
2. Licensure, certification and credential verification
3. reference check from previous employees
4. Nurse Aide registry check

Employee files were reviewed on 3/30/17. Review of the screening documentation indicated that Employee C, a Certified Nursing Assistant,(CNA) was hired 2/1/17 and had been employed in Georgia a few years prior to employment at the facility. The facility was unable to provide evidence that the Georgia Nurse Aide Registry check was obtained prior to employment. During interview on 3/30/17 at 11:45 A.M., the Administrator said that the Massachusetts Certified Nursing Assistant (CNA) registry was checked as well as the bordering state CNA registry, he said that the Georgia CNA registry had not been checked.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and staff interviews, the facility failed to update the care plan for 1 Resident (#6) in a total sample of 15 residents.

Findings include:

For Resident #6, the facility failed to update the fall care plan with comprehensive individualized interventions following falls. The clinical record was reviewed on 3/28/17. Resident #6 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 had a moderately impaired cognitive status which indicates poor decision making and requires cues/supervision. The MDS further indicated that Resident #6 required extensive assistance of 2 staff for transfers and totally dependent on one staff member for bathing.

Review of the fall risk assessment dated [DATE] indicated that Resident #6’s fall risk score was 19, placing him/her at a high fall risk. Resident #6 had a care plan for falls in place, dated as created 10/2015, with the identified problems listed as: Fall risk/vision, potential for injury related to: decrease in activity, poor endurance, decrease in cognition, shortness of breath, legally blind and history of mechanical falls. The goal on the care plan was written as Resident will be safe and free from any injuries, will minimize the potential of significant injury relative to a fall and resident will be safe and free from injury due to visual deficits. The next review was dated 4/11/17.

The interventions/approaches to support the goal were listed as:

* Keep call light and most frequently used personal items within reach, encourage resident to call for assistance if needed.
* Identification; maintain record of falls and evaluate for patterns.
* Alert staff that resident is at risk for falls.
* Update physical therapy, psychiatric services and pharmacy after every fall. * Totally dependent for transfers.
* Extensive assist time 2 for toileting.
* No clutter in pathways. * Fall risk assessment initially, annually, quarterly and as needed.
* Wheelchair most of time with assist.
* Floors clean and dry.
* Strip alarm to bed and chair at all times.
* Physical therapy/occupational therapy screen and evaluation if ordered by medical doctor.
* Non skid socks on at hour of sleep
* Eye consult yearly and as needed with eye service provider.

Review of the facility’s policy titled: Fall Risk Identification and Procedure policy, not dated, indicated the purpose was to ensure that resident safety is a primary consideration in overall care and treatment. The policy further indicated that all residents will be assessed for risk for fall and subsequent injury upon admission, readmission, or whenever there is a fall. The section titled procedure, indicated that in the event of a fall, a licensed nurse will: complete a facility incident report, complete a post falls report, document on the interdisciplinary restraint/positioning sheet the results of the post-fall investigation and the plan of care to manage future risk associated with falls and add appropriate interventions to the resident’s care plan. The section addressing interventions for falls indicated that all fall care plans were to be updated on the day of the fall. Documented falls on the Incident/Accident Report and Investigation included the following: Fall on 1/11/17, at 3:15 A.M., Staff observed resident on the floor next to her bed in sitting position, able to move all extremities. Resident was bleeding from back of his/her head on right side. Physician order [REDACTED]. The incident/accident report indicated that steps to prevent reoccurrence: chair and bed alarm in place, an intervention that was already in place on the care plan. The care plan failed to be updated with an intervention related to the fall on 1/11/17.

Fall on 2/16/17, at 2:55 A.M., Resident observed sitting on the floor by her bedside. Stated he/she was trying to get into his/her wheelchair. Bed alarm was plugged in but not sounding at time of fall. No injury noted. Review of the incident/accident report indicated under steps to prevent reoccurrence, that a new alarm was placed on the bed and to continue to check placement and proper functioning of alarms each shift (an intervention that was already present on the care plan and physician’s orders [REDACTED]. The care plan failed to indicate any new intervention related to the fall out of bed on 2/16/17. During interview and review of Resident #6’s care plan on 3/29/17 at 2:50 P.M., the Minimum Data Set (MDS) Coordinator said that she updated the care plans and that her former DON would also assist with updating care plans. The MDS Coordinator said the care plan was updated with the dates of the falls, but there was no new intervention related to the falls dated 1/11/17 and 2/16/17. During interview on 3/30/16 at 4:07 P.M., the Director of Nurses, who was precepting the new DON, said the intervention for 2/17/17 fall included the new bed alarm. The DON agreed that the bed alarm was not a new intervention and that the care plan had not been updated with new interventions related to the falls on 1/11/17 and 2/16/17.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure nursing staff provided services in accordance with professional standards of quality for Resident #2, and failed to ensure medications were administered with time parameters as specified in the Facility Policy for two residents ( Non-sampled {NS} #1 and Resident #9 in a total sample of 15 residents

Findings include:

1. For Resident #2, the facility staff failed to follow medication standards to ensure the medication was administered correctly and within parameters. On 3/29/17 at 8:38 A.M., during the observation of a medication pass, Nurse #4 was preparing the medication, [MEDICATION NAME] (a medication indicated for heart failure, [MEDICAL CONDITION] and acts by slowing and strengthening the heart beat), for administration. Nurse #4 entered Resident #2’s room and obtained her/his vital signs using a blood pressure cuff and pulse oximeter/pulse readout. Nurse #4 did not obtain an apical pulse for one full minute prior to administering the medication. According to the Davis Drug Guide the nurse must monitor the apical pulse (located over the heart) for one full minute. The drug should be withheld if the pulse rate is less than 60 beats per minute for adults.

Nurse #4 was interviewed on 3/29/17 at 8:56 A.M. Surveyor #1 asked Nurse #4 if there were any parameters or nursing standards for the administration of [MEDICATION NAME] or if she were aware of the Facility’s policy regarding the administration of [MEDICATION NAME]. At first, Nurse #4 said that she takes a regular pulse, then hesitated, and looked at the Medication Administration Record [REDACTED]. The Director of Nursing (DON) was interviewed on 3/29/17 at 9:15 A.M. The DON said that the Nursing standard was to take an apical pulse for one minute prior to administering [MEDICATION NAME] and to hold the medication if the pulse rate was less than 60 beats per minute.

2) For Non-sampled Resident #1 and Resident #9, the Facility failed to ensure that nursing staff administered medications within time parameters as specified in the Facility policy regarding medication administration times. On 3/28/17 at 3:40 P.M., during the observation of a medication pass, Nurse #2 began administering medications to Non-sampled Resident #1 at 3:40 P.M. and Resident #9 at 3:43 P.M The medications were ordered to be administered at 5:00 P.M. Review of the Facility policy for Medication Administration Times dated 5/1/10, section on procedure, point 1., indicated that medication times should commence within 60 minutes before the designated times of administration and should be completed 60 minutes after the designated times of administration. After the medications were passed, Surveyor #1 asked Nurse #2 why she gave the medications before the one hour window as allowed per Facility policy. Nurse #2 said that is when she usually does them. The DON was interviewed on 3/29/17 at 9:15 A.M. The DON said that the Facility’s policy was to give medications within the one hour before or after window of time. If there were special circumstances, then the physician should be notified to adjust the times.

Failed to peovide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews for 3 residents Resident (#2, #7 and #8), out of a total of 15 sampled residents, the Facility failed to complete treatments in accordance with the residents’ medical plan of care.

Findings include:

1) For Resident #7, the facility failed to use the hand splint provided by physical therapy and ordered by the physician. Review of Resident 7’s record indicated that he/she was admitted to the Facility in 10/2014 with [DIAGNOSES REDACTED]. The Resident had a contracture of the right hand and an open, flaccid left hand. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 was totally dependent for care and required required a hoyer lift for transfers. The Resident was non-ambulatory and required a Broda chair for mobility. Resident #7’s cognition was moderately impaired and he/she was non-verbal. Review of the physician’s orders [REDACTED].#7 was to wear a splint to right hand, 24 hours a day. Off with A.M. and P.M. care for skin checks.

On 3/28/17 at 11:15 A.M., Resident #7 was observed in bed, sleeping with a rolled washcloth in his/her right hand.

On 3/28/17 at 12:50 P.M., Resident #7 was observed receiving a GT feeding and there was a rolled washcloth in his/her right hand.

On 3/29/17 at 1:38 P.M., Resident #7 was observed in bed, sleeping with a rolled washcloth in his/her right hand.

The Director of Nursing (DON), who was orienting to the position, and the preceptor DON were interviewed on 3/29/17 at 1:15 P.M., They said that they were not able to find the Resident’s splint that Physical Therapy had provided for the Resident’s contracture. Nurse #1, who was caring for the Resident said that the splint was discontinued because the strap was making the back of the Resident’s hand red, but there was no nursing, rehabilitation therapy note or physician’s note to discontinue the splint and use a rolled washcloth in the Resident’s hand. The Certified Nurse Assistant (CNA #1) who was consistently assigned to the Resident was interviewed on 3/29/17 at 1:42 P.M,. CNA #1 said that the hand splint was breaking down the back of the Resident’s hand and the Physical Therapist (PT) told them they could use a rolled washcloth instead. CNA #1 said he could not remember when this change occurred, but it had been for some time now.

On 3/29/17 at 1:54 P.M., the DON said that the PT said the splint was a 2 inch round sponge with a single strap that went around the Resident’s hand. The DON said that the PT told the staff that a rolled washcloth would achieve the same goal if the splint was breaking the Resident’s skin down. However, there was no documentation by the PT, nursing staff or a new physician’s orders [REDACTED]. The DON said she would have medical records pull the old nursing notes to see if there was any documentation about the splint. The DON said she was unable to find any documentation about the splint and replacing it with a rolled facecloth anywhere in the medical record.

On 3/30/17 at 10:45 A.M., the DON in training and the preceptor DON said they found the Resident’s hand splint in the Resident’s bedside drawer. The splint was a sponge inside a soft nylon material which had a soft, puffy continuous wrap that went around the back of the hand and Velcro closed. There were no sharp or rough edges. The splint appeared to be washed and free of visible soil or odor. The two DONs said they would put it on the Resident’s hand and they were overheard phoning the physician to notify they had found it and were seeking approval to continue it’s use.

2. For Resident #2 the facility failed to provide orthostatic blood pressure ( blood pressure taken in the lying, sitting and standing position) as indicated by physician orders. Resident #2 was admitted to the facility during 12/2014 with [DIAGNOSES REDACTED]. The medical record was reviewed on 3/28/17. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated that Resident #2 had a brief interview for Mental Status ( BIMS) score of 9/15, which indicated moderate cognitive impairment, required extensive assistance of one staff for transfers, dressing and bathing. The MDS also indicated that Resident #2 used oxygen therapy. Review of the Physician orders [REDACTED].#2 had an order for [REDACTED].>Review of the Medication Administration Record [REDACTED]. During interview and review of the MAR indicated [REDACTED].M., Nurse #2 said it does not look like it was done, to be honest. She said that orthostatic blood pressures were being discontinued for many residents but said that Resident #2 still had the order in place to check orthostatic blood pressure monthly.

3. Resident #8 was admitted to the facility in 6/2015. The resident’s [DIAGNOSES REDACTED]. a. Review of the Physician’s 3/2017 treatment orders indicated the following: Keep left leg elevated at all times. The resident was observed on the following dates and times in his/her wheelchair with his/her left leg always on the floor:

*. 3/28/17 at 12:00 P.M.,12:30 P.M.
*. 3/29/17 at 8:25 P.M.,10:50 A.M. and 2:45 P.M.
*. 3/30/17 at 9:15 A.M.

On 3/30/17, an interview was held with the Director of Nursing. The above observations were discussed with her. She said she understood it to be a problem and would address it

. b Resident #8 had a 3/2017 physician’s orders [REDACTED]. Review of the Treatment Administration Record (TAR) indicated the resident’s B/P was not recorded on 3/15/17 and 3/29/17.

c Resident #8 had a 3/2017 physician’s orders [REDACTED].M. shift as well as a physician’s orders [REDACTED].M.-3:00 P.M. shift. Review of the 3/2017 TAR indicated they were not recorded as ordered.

On 3/30/17 at 2:00 P.M., the above findings were discussed with the Director of Nursing. She said she would address the issue.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that 1 resident (#8), was properly supervised and assisted to prevent a fall with injury and 1 resident (#4) who sustained 8 falls in a 6 month period, in a sample of 15 residents.

Findings include:

1. For resident #8, the facility failed to properly supervise the resident during a transfer and the resident suffered an injury requiring stitches as a result. Resident #8 was admitted to the facility in 6/2015. The resident’s [DIAGNOSES REDACTED]. The resident is alert and oriented to person, place and time and cognition is within normal limits.

The Quarterly Minimum (MDS) data set [DATE] identified the resident as having short and long-term memory loss and moderately impaired cognition. In addition, the resident required a 2 person assist in transfers, was non-ambulatory and had a history of [REDACTED]. The resident’s care plan addressed the problem of Falls. It indicated the following:

* Potential for injury related to: unsteady gait, decreased endurance, impulsive related to long standing mental health issues.

Goal:
* Resident will be safe and free from any injuries.
* Will minimize the potential of significant injury relative to a fall.
* Resident will accept assistance from staff for all transfers. Interventions included: Toileting/Transfer Status: Totally dependent.

Review of the resident’s status sheet (care card) indicated the resident was a 2 person transfer.

On 3/29/17, review of the 11/08/16 nursing note at 8:45 P.M., indicated that during a transfer with the certified nurse aide from the wheelchair to the bed, the resident hit his/her forehead on his/her bedside table causing a deep laceration above his/her left eye, approximately 1 inch long. The resident experienced a small amount of bleeding and was sent out to the emergency room.

On 3/29/17, review of the facility’s Incident/Accident report indicated that on 11/08/16 at 8:45 P.M., the resident was transferred by 1 aide (instead of the required 2 person assist) from his/her wheelchair to bed. The resident slumped down hitting his/her left forehead on the bedside table causing a 1 centimeter laceration. The resident was sent out to the emergency room and received 4 sutures.

A review of the incident investigation dated 11/8/16 included a statement by the aide that he/she went to transfer (the resident) to (his/her) bed and during the transfer with (resident) being slumped over (he/she) banged (his/her) head on the corner of the table. The resident was observed on 3/28/17 at 12:00 P.M. eating his/her lunch in the Day room. Shortly thereafter, he was observed wheeling himself/herself down the hallway.

On 3/29/17 at 8:25 A.M. and 11:15 A.M. and 3:50 P.M. the resident was observed sitting in his/her wheelchair in his/her room. On 3/30/17 at 2:00 P.M., the 11/08/16 incident was discussed with the Director of Nurses. She said she was only vaguely familiar with the incident as she was only recently hired. She said the aide was re-educated at the time of the incident that the resident requires a 2 person assist in transfers at all times.

2. For resident #4, the facility failed to provide proper supervision and revise and develop effective falls interventions to keep the resident safe. The resident suffered 8 falls over a 6 month period. Resident #4 was admitted to the facility in 9/28/16. The resident’s [DIAGNOSES REDACTED]. The fall risk assessments dated 9/28/16 and 10/03/16 identified the resident as scoring at 11 and being at high risk for falls. Record review indicated the resident received Occupational Therapy Services between 9/29/16-10/27/16.

The Initial Minimum (MDS) data set [DATE] identified the resident as being alert and oriented and exhibiting behavioral symptoms not directed towards others. He/she required extensive assist of 1 in transfers, ambulation and toileting. In addition, the resident was continent of bowel and bladder and he/she experienced 1 fall with no injury and 1 fall with minor injury since admission or prior assessment. The falls care plan dated 10/03/16 identified the following problem: at risk for falls. Interventions included:
*Keep call light and most frequently used personal items within reach. Encourage resident to call for assistance.
*Maintain record of falls and evaluate for patterns. Alert staff that resident is at high risk for falls.
*Toileting Status: Extensive assist X 1
*No clutter in pathways
*Floors clean and dry
*Flag door with red heart signifying High Fall Risk resident.

Review of a 10/03/16 Incident/Accident Report indicated the resident’s roommate was yelling out for help. The resident was observed lying on the floor in urine with socks on next to the bathroom door. He/she sustained a quarter size lump on the left side of his/her head. The resident was sent to the hospital and a CT scan done was negative. The resident was identified as having an unsteady gait, was hurrying out of bed and was not assisted. It was determined the resident had on ill fitting socks and was ambulating himself/herself. Review of the 10/07/16 Incident/Accident Report indicated the resident fell at 12:45 A.M. The resident was observed sitting on the floor by his/her bedside. The resident said that he/she was coming back from the bathroom and tripped over his/her wheelchair that was near his/her bed. No injury noted. The resident was receiving physical therapy and occupational therapy services at the time of the fall. Recommendations made:

bed and chair alarms. The resident’s fall care plan was updated to include the following interventions:
*bed and chair alarm *non-skid socks when not wearing socks at night
*make sure room free from clutter
*encourage resident to call for assist The resident’s fall care plan was updated again on 10/16/16 through 4/08/17 and included the following interventions: *Alert staff that resident is at risk for falls
*Redirect and educate for safe practices *Update Physical Therapy (PT), Psych and Pharmacy after every fall
*PT/OT (Occupational Therapy) screen and eval if ordered by M.D. *Toilet/Transfer Status:Extensive assist X 1
*Wheelchair with assist

Review of the 1/08/17 Incident/Accident Report indicated the resident was heard calling out for help at 8:30 A.M. The resident was observed lying on the floor half way in the bathroom. The resident said he/she lost his/her balance. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall). The Post Fall Report indicated an alarm was not identified as being in use. Review of the Restraint/Positioning Assessment (conducted for those residents who are at high risk for falls) dated 1/08/17 indicated the resident’s cognition status was moderately impaired; risk factors included the use of psychotropics, poor balance and agitation. The resident required supervision in ambulation, had an unsteady gait and had moderately impaired judgement/memory. The resident forgets he/she cannot walk independently, has a history of falls/fractures and engages in physically aggressive behavior towards staff/residents. The resident fell again on 1/08/17 at 3:25 P.M. Review of the Incident/Accident Report indicated the resident was found on the bathroom floor. The resident said he/she had slid off the wheelchair while trying to get on the toilet. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall). The Post Fall Report indicated an alarm was not identified as being in use.

Review of the 1/10/17 Incident/Accident Report indicated the resident was observed at 4:45 P.M. sitting on the floor next to his/her bed. Urine was on the floor. No injuries were noted. Additional steps taken to prevent recurrence: chair alarm (this intervention was already in place and noted to not be on at the time of the fall. The 1/10/17 Post Fall Report indicated an alarm was not identified as being in use. The resident was identified as having a urinary tract infection. No further recommendations were made. Review of the Nursing screening request on 1/08/17 and 1/10/17 for falls indicated the resident refused Occupational and Physical Therapy treatment.

Review of the 1/14/17 Incident/Accident Report indicated the resident was observed sitting on the floor next to his/her wheelchair at the end of his/her bed. He/she said he/she was going to the bathroom. The resident took the alarm off and refused to have it on. The resident did not sustain an injury. Steps taken to prevent recurrence: remind resident to ask for assistance when transferring to the bathroom or bed. The 1/14/17 Post Fall Report indicated the resident’s brakes were not locked, an alarm was not in use and had a history of [REDACTED]. Nursing notes written on 1/19/17 and 1/20/17 indicated the resident shut off his/her bed alarm and threw it under the bed.

A 1/21/17 nursing note indicated the resident removes alarms. It further indicated they should be on secondary to falls. The Quarterly MDS dated [DATE] identified the resident as being alert and oriented, requiring extensive assist of 1 in transfers ambulation and toileting. The resident was frequently incontinent at the time and had fallen twice with no injuries. Review of the 1/24/17 Incident/Accident Report indicated the resident was observed at 8:30 P.M. sitting on the floor next to his/her bed. The report indicated the resident was attempting to self toilet himself/herself and had disconnected the alarms. The resident was identified as being alert and confused. Additional steps taken to prevent recurrence: Cautioned resident to ring call bell for assistance and not to disconnect his/her alarm for safety. The Restraint/Positioning assessment dated [DATE] indicated the resident’s cognitive status was moderately impaired. Risk factors included receiving antihypertensives and psychotropics. The resident required physical assistance in toileting. The Post Fall Report dated 1/24/17 identified the resident as being barefoot. Record review indicated the resident received Occupational Therapy services 1/24/17 through 2/26/17. The reason for discharge was the resident’s refusal of treatment. The 2/2017 falls care plan was updated with the following information: Three falls this quarter. Urinary tract Infection during the period of first two falls. Will dis-alarm bed alarm and ambulate/transfer self to bathroom. educated on safety and encouraged to call for assist. continue to monitor. Review of the 3/16/17 Incident/Accident Report indicated the resident was observed sitting on the floor ay 8:50 P.M. beside his/her bed. The resident said he/she was going to the doorway to ask for help to move over the bedside table. No injury. Additional steps taken to prevent recurrence: impulsive. Continue alarms bed/chair. Remind to call for assistance. Refused room change for closer monitoring. Record review indicated the resident refuses Physical Therapy services. A 3/23/17 nursing note indicated the resident’s bed and chair alarms were discontinued due to the resident’s refusal to have them on.

On 3/28/17 at 12:10 P.M., the resident was observed in the small day room eating lunch. On 3/29/17 at 8:20 A.M., the resident was observed awake and resting in bed. A red heart was not on the resident’s door to signify the resident was a High Fall Risk, as per facility practice.

On 3/29/17 at 2:00 P.M., the resident was observed sitting in the hallway in his/her wheelchair, smiling and waving. The facility failed to provide proper supervision and address the fact that the resident was identified for 7 of 8 falls, between 10/03/16 and 2/06/17, as having either been incontinent or on his/her way to the bathroom. On 3/30/17 an interview was held with the resident’s certified nurse aide #2. She said the resident still continues to toilet herself without asking for help and that she had just found her earlier in the bathroom by himself/herself.

Failed to properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow their policy/protocol in providing comprehensive treatment in the use of nebulizer treatment with post treatment assessment for 1 (#2) Resident in a total sample of 15 residents.

Findings include:

For Resident #2 the facility failed to provide a post treatment assessment to measure the effectiveness of the nebulizer treatment. Review of the facility’s respiratory treatment policy, not dated, indicated that it is the policy of the facility to document on all nebulizer treatments. The policy indicated that the medication nurse is to keep accurate and orderly records by documenting lung sounds and oxygen saturation, using the oximeter, prior to treatment and again post treatment to measure the effectiveness of the nebulizer treatment.

Resident #2 was admitted to the facility during 12/2014 with [DIAGNOSES REDACTED]. The medical record was reviewed on 3/28/17. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated that Resident #2 had a brief interview for Mental Status (BIMS) score of 9/15, which indicated moderate cognitive impairment, required extensive assistance of one staff person for transfers, dressing and bathing. The MDS also indicated that Resident #2 used oxygen therapy. Review of the physician’s orders [REDACTED].#2 had an order for [REDACTED]. On 3/29/17 at 8:52 A.M., Nurse #4 was observed by Surveyor#1, administering a nebulizer treatment with Resident #2. Resident #2 was difficult to arouse, had visible retractions with respirations (using chest muscles to breathe) and had forced expirations. Nurse #4 said the Resident had just resumed smoking the prior evening and seemed to have clinically declined as a result. Nurse #4 asked the Resident to sit up so that she could listen to her/his breath sounds, but the Resident refused. Nurse #4 administered the nebulizer treatment, but did not obtain and document the post treatment breath sounds and oxygen saturation post-treatment per Facility policy. Based on the Resident’s compromised respiratory status – increased effort during respirations- it was clinically indicated to re-assess the Resident post treatment.

Review of the Medication Administration (MAR) record dated 3/2017 indicated that Resident #2 had the nebulizer treatment administered at 12:00 A.M., 4:00 A.M., 8:00 A.M., and 12:00 P.M., 3/1/17 through 3/28/17.

Review of the Respiratory flow sheet dated 3/2017 indicated that lung sounds and oxygen saturation were recorded, and oxygen was documented as running at 3 liters each shift (11:00 P.M., 7:00 A.M., and 3:00 P.M.), from 3/1/17 through 3/28/17. The respiratory flow sheet failed to have any post treatment assessments completed to record the effectiveness of the nebulizer treatments. During interview with Nurse #1 on 3/30/17 at 3:15 P.M., she said the nurse who administers the nebulizer treatment does a post treatment assessment and it should be recorded on the respiratory flow record. When flow sheet for 3/ was reviewed, she said that the nurses sign off on the flow sheet but must of got caught up and did not return to the flow sheet to document the post treatment assessment. During the exit conference on 3/30/17 at 5:30 P.M., the Director of Nursing said she did not know why the nursing staff were not documenting the post treatment assessments.

Failed to store, cook, and serve food in a safe and clean way

Based on observation and staff interview, the facility failed to ensure that proper food service sanitation practices were followed.

Findings include:

On 3/27/17 at 11:20 A.M., the Surveyor #3 entered the kitchen to observe the tray line. The Food Service Supervisor (FSS) was observed to be in the kitchen and not wearing a hair net.

The cook was observed taking temperatures without sanitizing the thermometer after testing each of the food items. She first tested the hamburger and without sanitizing the thermometer, she immediately tested the beans. She then tested the tomatoes and ground meat with the same thermometer.

On 3/29/17 at 3:00 P.M., the kitchen sanitation tour was conducted. The following was observed:

*The hot water/coffee machine had an unidentified heavy white substance build-up around the spigot. The cook said he did not know what the substance was. The diet aide said the machine was cleaned the day before.

* A large mixing bowl stored clean had unidentified white powder substances inside the bowl. On 3/30/17 at 7:17 A.M., Surveyor #2 went to the kitchen to interview the FSS and observed the FSS standing in the kitchen without a hair net on.

On 3/30/17 at 10:10 A.M., an interview was held with the FSS to discuss the above findings. The interview was held in the FSS’s office attached to the kitchen. She was not wearing a hair net. The FSS said that everyone has to wear a hair net when they are in the kitchen. She said she is the one who enforces it, everyone has to wear a hair net, no matter what.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on observations and staff interviews, the facility staff failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy on 1 of 2 units observed. In addition, the Facility failed to ensure that the medication cart was locked and that medications were not left unsupervised on top of the medication cart.

Findings include:

1) On 3/28/17 at 7:00 A.M., Surveyor #2 noted that the medication cart located at the end of the nursing station and the center of A, B and C hallways and a short distance from the entrance door, was unlocked. Surveyor #2 approached the cart and was able to open medication drawer. There were no staff present at the time the unlocked cart was observed. Clinical staff and non-professional staff were observed to be walking in the vicinity of the open medication cart at that time.

2) On 3/28/17 at 4:55 P.M., as Surveyor #1 approached the medication cart where Nurse #2 was continuing to pass medications, Surveyor #1 noted that the the medication cart was unattended and in the hallway where residents, staff and some visitors were walking about. Surveyor #1 remained at the medication cart until Nurse #2 returned to the medication cart. Surveyor #1 noted that an emesis basis containing 8 multi-use vials of insulin was on the top of the medication cart . When Nurse #2 returned to the medication cart, Surveyor #2 pointed out the emesis basis containing the multi-use insulin vials which was left unattended in the hallway. Nurse #2 said that insulin is not a medication. Surveyor #1 said that insulin was considered a medication and therefore should not be left unattended. Nurse #2 then said that she was busy with another resident who needed a pain medication. Review of the Facility policy titled General Dose Preparation and Medication Administration dated 1/1/13, point 3.9 indicated that facility staff should not leave medications or chemicals unattended

3) The Medication Room was observed on 3/29/17 at 2:50 P.M. with Nurse #4 and the Unit Manager present. The following observations were made: *Two boxes containing 10 syringes and one box containing 9 syringes of Enoxaparin Sodium (an anti-coagulation medication) were labeled with an expiration date of 12/2016. *One jar of hemorrhoid pads with a blurred expiration date, but visible number 15. Nurse #4 assumed the expiration year was 2015 and removed the jar. 4) The medication refrigerator was noted to have a seal which was observed to have black areas in the folds and several dry, cracked areas.

Failed to make sure medically necessary lab services/tests are ordered by the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory for 1 resident (#4) in a sample of 15 residents.

Findings include:

Resident #4 was admitted to the facility in 9/2016. The resident’s [DIAGNOSES REDACTED]. Record review indicated a physician’s lab order for Lipids and TSH to be done in January. Record review further indicated that these lab reports were not filed in the resident’s record. An interview was held with U.M. #1 on 3/29/17 and she confirmed that neither lab was drawn as ordered.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for sample residents ( #2, #3, #8, #9, #10, #13) in a total sample of 15 residents.

Findings include:

1. For Resident #2 the facility failed to have a complete and accurate consent form for [MEDICAL CONDITION] medication and failed to have complete and accurate documentation on the respiratory flow sheet for the post treatment to measure the effectiveness of the nebulizer treatment.

a. Resident #2 was admitted to the facility during 12/2014 with [DIAGNOSES REDACTED]. Review of the medical record on 3/28/17 indicated that Resident #2 had physician orders [REDACTED]. Review of the [MEDICAL CONDITION] consent form for [MEDICATION NAME] indicated that the space provided for dosage range had written in: see attached sheets. The consent failed to have sheets attached. The space on the form titled: last reviewed by facility was left incomplete. Review of the [MEDICAL CONDITION] consent form for [MEDICATION NAME] indicated that the space provided for dosage range had written in: see attached sheets. The consent failed to have sheets attached. The space on the form for last reviewed by facility, was left incomplete. Review of the [MEDICAL CONDITION] consent form for [MEDICATION NAME] indicated that the space provided for dosage range was documented as; see attached sheets. The consent form failed to have sheets attached that included the dosage range for the consented medication. The space on the form titled; last reviewed by facility, was left incomplete. b. Review of the facility’s respiratory treatment policy, not dated, indicated it is the policy of the facility to document on all nebulizer treatments; the medication nurse is to keep accurate and orderly records documenting lung sounds and oxygen saturation, using the oximeter, prior to treatment and again post treatment to measure the effectiveness of the nebulizer treatment. The medical record was reviewed on 3/28/17. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated that Resident #2 had a brief interview for Mental Status ( BIMS) score of 9/15, which indicated moderate cognitive impairment, required extensive assistance of one staff person for transfers, dressing and bathing. The MDS also indicated that Resident #2 had the special treatment of [REDACTED]. Review of the Physician orders [REDACTED].#2 had an order for [REDACTED]. Review of the Medication Administration (MAR) record dated 3/2017 indicated that Resident #2 had the nebulizer treatment administered at 12:00 A.M., 4:00 A.M., 8:00 A.M., and 12:00 P.M., 3/1/17 through 3/28/17. Review of the Respiratory flow sheet dated 3/2017 indicated that lung sounds were recorded, oxygen saturation was recorded and oxygen was running at 3 liters each shift ( 11:00 P.M., 7:00 A.M., and 3:00 P.M.,) from 3/1/17 through 3/28/17. The respiratory flow sheet failed to have any post treatment assessments completed to record the effectiveness of the nebulizer treatment. During interview with Nurse #1 on 3/30/17 at 3:15 P.M., she said the nurse who administers the nebulizer treatment does a post treatment assessment and it should be recorded on the respiratory flow record. When the respiratory flow sheet for 3/ was reviewed, she said that the nurses sign the flow sheet and must of got caught up and did not return to the flow sheet document the post treatment assessment. During exit conference on 3/30/17 at 5:30 P.M., the Director of Nursing said she could not say why the nebulizer post treatment was not completed.

2) For Resident #3, the facility failed to have a complete and accurate consent form for [MEDICAL CONDITION] medication. Resident #3 was admitted to the facility during 2/2016 with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #3 had physician orders [REDACTED]. Review of the [MEDICAL CONDITION] consent form for [MEDICATION NAME] indicated that the space provided for dosage range was documented as see attached sheets, but there was no sheet indicating the dosage for the amount of medication consented. The space on the form titled: last reviewed by the facility was left incomplete.

3) For Resident #9 the facility failed to have a complete and accurate consent form for [MEDICAL CONDITION] medication. Resident #9 was admitted to the facility during 7/2011 with [DIAGNOSES REDACTED]. Review of the medical record on 3/28/17 indicated that Resident #9 had physician orders [REDACTED]. Review of the [MEDICAL CONDITION] consent form for [MEDICATION NAME] indicated that the space provided for dosage range was documented as; see attached sheets. The consent failed to have sheet attached for dosage range for the consented medication. The space on the form titled: last reviewed by facility was left incomplete.

4) For Resident #10, the facility failed to have a complete and accurate consent form for [MEDICAL CONDITION] medication. Resident #10 was admitted to the facility during 6/2013 with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #10 had physician orders [REDACTED]., [MEDICATION NAME] 300 mg., [MEDICATION NAME] 50 mg., [MEDICATION NAME] 2.5 mg. and 5 mg. and [MEDICATION NAME] 0.5 mg. Review of the [MEDICAL CONDITION] consent forms for the above indicated that the space provided for dosage range was documented as see attached sheets, but there was no sheet indicating the dosage for the amount of medication consented. The space on the form titled: last reviewed by the facility was left incomplete.

5) For Resident #13, the facility failed to have a complete and accurate consent form for [MEDICAL CONDITION] medication. Resident #13 was admitted to the facility during 3/2017 with [DIAGNOSES REDACTED]. Review of the medical record indicated that Resident #13 had physician orders [REDACTED]. The Resident was also ordered [MEDICATION NAME] 50 mg., but there was no consent form in the medical record. Review of the [MEDICAL CONDITION] consent forms for the above indicated that the space provided for dosage range was documented as see attached sheets, but there was no sheet indicating the dosage for the amount of medication consented. The space on the form titled: last reviewed by the facility was left incomplete. During interview on 3/28/17 at approximately 11:30 a.m., the Staff Develop Coordinator ( SDC) said she had attached the list of medications to the consent, including dosage and mailed the consents to the residents responsible person. She said the attached list with medication range must of been kept by the responsible person. During interview on 3/29/17 at 11:25 A.M., the Director of Nursing said she did not like the system of attaching the dosage and it should be documented directly on the consent form.

7) Resident #8 was admitted to the facility in 6/2015. The resident’s [DIAGNOSES REDACTED]. Review of the Physician’s 3/2017 treatment orders indicated the following: Keep left leg elevated at all times. The resident was observed on the following dates and times in his/her wheelchair with his/her left leg always on the floor: *. 3/28/17 at 12:00 P.M., 12:30 P.M. *. 3/29/17 at 8:25 A.M., 10:50 A.M. and 2:45 P.M. and 3:50 P.M. *. 3/30/17 at 9:15 A.M. Review of the 3/2017 Treatment Administration Record (TAR) indicated that nursing staff had documented the residents’ left leg was elevated at all times during the 7:00 A. M.-3:00 P.M. and 3:00 P.M.-11:00 P.M shift. On 3/30/17 at 2:00 P.M., an interview was held with the Director of Nursing. The above observations were discussed with her. She said she understood it to be a problem and would address it.

Baker-Katz 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

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Sources:

Medicare Nursing Home Profiles and Reports – Baker-Katz Nursing Home

Inspection Report for Baker-Katz Nursing Home – 03/30/2017

Page Last Updated: August 9, 2018

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