Eliot Center for Health and Rehabilitation

Eliot Center for Health and Rehabilitation

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Eliot Center for Health & Rehabilitation? Our lawyers can help.

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About Eliot Center for Health & Rehabilitation

Eliot Center for Health & Rehabilitation is a for profit, 114-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Wellesley, Framingham, Wayland, Needham, Ashland, Weston, Holliston, Medfield, Sudbury,  Westwood, Newton, Waltham, Southborough, Hopkinton, Dedham, and the other towns in and surrounding Middlesex County, Massachusetts.

Eliot Center for Health & Rehabilitation
168 W Central St,
Natick, MA 01760

Phone: (508) 655-1000
Website: http://eliotcenterrehab.com/

CMS Star Quality Rating

Eliot Center for Health and RehabilitationThe 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, Eliot Center for Health & Rehabilitation in Natick, 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 3 out of 5 (Average)

Fines Against Eliot Center for Health & Rehabilitation

The Federal Government fined Eliot Center for Health & Rehabilitation $35,139 on 03/22/2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Eliot Center for Health & Rehabilitation committed the following offenses:

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy reviews and record reviews failed to follow policy by not investigating investigate a fall for 1 resident (#12) in a total of 17 sampled residents. The facility staff also failed to complete the Nurse Aide Registry Screening for 2 of 5 employees upon hire, as required.

Findings include:

The facility policy titled Accident/Incident (A/I) form dated 4/2013 included : d.

The A/I report must be completed on the shift that the event occurred or was discovered. e. The nursing supervisor will immediately initiate an investigation for all accidents/incidents. The investigation will include written statements from staff members caring for the resident and from persons having knowledge of the event. The investigation will be completed within 72 hours of incident.

f. The nursing supervisor/designee records his/her investigative findings and conclusions.

g. The DNS reviews all A/I reports to ensure accurate and complete documentation of the incident, and to determine if there is credible evidence to substantiate the allegation of abuse, neglect, or mistreatment.

h. All occurrences will be reviewed by the Administrator and DNS. Occurrences which have been classified at the accident level or resident-resident altercation will be identified and measures implemented to prevent reoccurrences.

1. For Resident #12, the facility staff failed to complete a thorough investigation after the resident sustained [REDACTED]. Resident #12 was admitted to the facility in 1/2016, with [DIAGNOSES REDACTED]. Review of the Nurse’s Notes, dated 1/15/17, indicated that the resident sustained [REDACTED]. Review of the Accident/Incident Report, dated 1/15/17, indicated a blank Supervisor’s A/I Investigation form and a blank Summary of Investigation Form. Review of the Quarterly MDS Assessment, with an ARD of 3/10/17, indicated a BIMS score of 10 out of 15 (moderate cognitive impairment). Section J1900 of the MDS indicated that the resident had one fall since the prior assessment. During an observation, on 3/22/17 at 9:30 A.M., the resident was lying in his/her bed with eyes closed, and the 2 1/2 side rails were observed in the up position. The surveyor observed a floor mat next to the window side of the resident’s bed, and a motion sensor in place. During an interview, on 3/22/17 at 2:15 P.M.,the DNS said she did not complete the Supervisor’s A/I Investigation form and she did not complete the Summary of Investigation Form for this incident, as per policy.

2. The facility failed to follow policy to complete the required Nurse Aide Registry screening, of potential new employees, for a history of abuse, neglect or mistreatment of [REDACTED].#1 and #2). Review of the facility Abuse Policy and Procedure, dated as revised 11/2016, indicated that screening of all potential employees would include checking and verifying the Certified Nurse Aide (CNA) Registry. Review of the personnel file for new employee #1, hired 1/11/17, indicated a blank search results page dated 1/13/17, that had no identifying information. Review of the personnel file for new employee #2, hired 11/28/16, indicated a blank search results page dated 11/7/16, that had no identifying information. During an interview with the facility Administrator on 3/21/17 at 2:00 P.M., she said that the CNA Registry checks should be completed prior to hire, and that the potential employee’s identifying information should be evident on the report.

Failed to review or revise the resident's care plan after any major change in a resident's physical or mental health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record record, the facility staff failed to complete a Significant Change Minimum Data Set (MDS) Assessment for 1 resident (#6), in a total of 17 sampled residents

Findings include:

Resident #6 was admitted to the facility in 4/2013, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 9/30/16, indicated that Resident #6 scored a 1 out of 27 for mood (indicating the presence of feeling tired or having little energy for several days), required supervision with the assist of 1 staff person for transfers, was continent of bladder and bowel, and did not experience significant weight changes (gain/loss).

Review of the next Quarterly MDS Assessment, with an ARD of 2/17/17, indicated the resident scored a 12 out of 27 for mood (indicating the presence of feeling down, depressed, or hopeless, feeling tired or having energy, feeling bad about him/herself ., and experienced troubled concentrating on things nearly every day), did not transfer during the assessment reference period, was frequently incontinent of bladder and bowel, and experienced a significant weight loss that was not prescribed by the physician. On 3/21/17 at 11:00 A.M., the surveyor observed Resident #6 lying in bed with 2 1/4 side rails in the up position. The resident was observed watching television in his/her room, and the call bell was within reach. During an interview, on 3/22/17 at 2:00 P.M., the Director of MDS said that a Significant Change Assessment should have been completed when the resident had a significant weight loss and a change in continence status.

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility staff failed to accurately code the resident’s status on the Minimum Data Set (MDS) Assessment for 4 sampled residents (#2, #4, #8 and #9), in a total sample of 17 residents

Findings include:

1. For Resident #2, the facility staff failed to accurately code restraint use on an Annual MDS Assessment. Resident #2 was admitted to the facility in 10/2012, with [DIAGNOSES REDACTED]. Review of the Annual MDS, with an Assessment Reference Date (ARD) of 11/18/16, indicated in Section P0100, that the resident had a restraint put on daily. Review of the Annual MDS, with an ARD of 1/8/16, indicated in Section P0100, that the resident was coded #2, (other) restraint daily. Review of the Quarterly MDS Assessment, with an ARD of 2/3/17, indicated in Section C1000, that the resident was moderately impaired for cognitive skills for daily decision making. In addition, Section P0100 of the MDS Assessment, indicated the resident utilized a restraint daily. Review of the Monthly Physician Orders, dated 3/1/17, indicated an order for [REDACTED]. During an observation, on 3/21/17 at 2:45 P.M., the resident was sitting in the unit dining room and was taking part in an activity program. The resident had a lap buddy in place, on the wheelchair. During an interview, at 3/21/17 at 9:45 A.M., the MDS Director said the Annual MDS, with an ARD of 1/8/16, Section P0100 was miscoded. She said the resident utilizes a lap buddy and the MDS did not indicate that information.

2. For Resident #4, the facility staff failed to accurately code the resident’s eating status, and to indicate the presence of an infection, on the MDS. a. Resident #4 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan Activity of Daily Living (ADL) Function/Rehab Potential, updated 2/18/17, indicated that the resident was independent for eating. Review of the Quarterly MDS Assessment, with an ARD of 2/1/17, indicated the resident had a Brief Interview for Mental Status score of 15 out of 15 (cognitively intact). Further review of the MDS, indicated that the resident required limited assist for eating with one person assist.

During an observation, on 3/16/17 at 1:15 P.M., the resident was lying in bed and was watching television. Resident was awake and was conversant with the surveyor. During an interview, on 3/17/17 at 7:45 A.M., Certified Nurse Aide #2 said that the resident was independent for eating. During an interview, on 3/17/17 at 10:00 A.M., Unit Manager #2 said that the resident was independent for eating. During an interview, on 3/17/17 at 10:30 A.M., the MDS Director said the Quarterly MDS with an ARD of 2/1/17, was miscoded and should have indicated that the resident was independent for eating.

b. Review of the Quarterly MDS Assessment, with an ARD of 2/1/17, indicated in Section I2300, that there was no Urinary Tract Infection [MEDICAL CONDITION] in the last 30 days. Review of the Microbiology Lab Result for Final Urine Culture, dated 1/4/17, indicated that the resident had Escherichia Coli (bacteria) in the urine. Review of the Nurse’s Notes, dated 1/5/17, indicated that the resident was readmitted to the facility from the hospital, with a discharge [DIAGNOSES REDACTED]. Review of the hospital Patient Discharge Plan, dated 1/5/17, indicated that the resident was hospitalized for [REDACTED]. Review of the physician’s orders [REDACTED]. Review of the Doctor’s Progress Notes, dated 1/7/17, indicated the resident had a UTI. During an interview, on 3/21/17 at 9:05 A.M., the MDS Director said the Quarterly MDS with an ARD of 2/1/17 was miscoded and should have indicated that the resident had a UTI in the past 30 days.

3. For Resident #8, the facility staff failed to accurately code the presence of a pressure ulcer and the severity of vision impairment on the MDS. Resident #8 was admitted to the facility in 9/2010, with [DIAGNOSES REDACTED]. a. Review of the Nurse’s Notes, dated 11/2/16, indicated an area on resident’s left gluteal fold had worsened and was now an open area and measurements were completed. Review of the Weekly Pressure Ulcer Sheet, dated 11/2/16, indicated that the excoriation progressed to an open area, and description and measurements were documented. Review of the Comprehensive Care Plan, Alteration in Skin, dated 11/2/16,indicated that the resident had an open area on left gluteal fold. Review of the Annual MDS Assessment, with an ARD of 11/4/16, indicated the resident was moderately impaired for cognitive skills for daily decision making. Review of Section M0210 of the Annual MDS Assessment, with an ARD of 11/4/16, indicated the resident did not have any one or more unhealed pressure ulcer at Stage 1 or higher. During an observation, on 3/21/17 at 12:20 PM., the resident was sitting in the unit dining room, in his/her gerichair, and was being fed by a staff member. Resident did not respond to the surveyor when called by name. During an interview, on 3/21/17 at 2:30 P.M., the MDS Director said Section M0210 on the Annual MDS Assessment, with an ARD of 11/4/16, was miscoded for pressure ulcer and should have indicated the resident had a pressure ulcer. b. Review of the Nurse Aide’s Information Sheet, undated, indicated that the resident had poor eyesight. Review of the Doctor of Optometry Consult, dated 8/10/16, indicated that the resident had moderate [MEDICAL CONDITION] in both eyes. Review of the Comprehensive Care Plan, Visual Function, reviewed 3/15/17, indicated that the resident had impaired vision. Review of the Quarterly MDS Assessment, with an ARD of 2/24/17, indicated in Section B1000 that the resident had adequate vision. During an interview, on 3/21/17 at 2:30 P.M., the MDS Director said that Section B1000 on the Quarterly MDS Assessment with an ARD of 2/24/17, was miscoded and should have indicated that the resident’s vision was impaired.

4. For Resident #9, the facility staff failed to accurately code an Admission MDS Assessment relative to [DIAGNOSES REDACTED]. Resident #9 was admitted to the facility 1/2017, with multiple [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 1/23/17, indicated Resident #9 had an active [DIAGNOSES REDACTED]. During an observation of Resident #9, on 3/22/17 at 10:10 A.M., the resident was lying in bed with the head of the bed up approximately 45 degrees. The resident was conversant and had a size 6.0 [MEDICAL CONDITION] and red Passy Muir valve (used to enable speaking) in place. There was a suction machine set up on a bed side table in the resident’s room. During interview with the MDS Coordinator, on 3/22/17 at 2:00 P.M., she said that the [DIAGNOSES REDACTED].

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 observation, interviews and record review, the facility staff failed to develop a comprehensive plan of care for 1 resident (#10), in a total of 17 sampled residents.

Findings include:

Resident #10 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/5/16, indicated that Resident #10 required extensive assistance of 2 staff for transferring, extensive assistance of 1 staff for locomotion on/off the unit, and was totally dependent for bathing, dressing, and personal hygiene. Review of the Nurse Aide’s Information Sheet, undated, indicated that the resident required total care for bathing, dressing, eating, and grooming.

On 3/17/17 at 7:40 A.M., the surveyor observed Resident #10 seated in a reclining chair in the dining room. The resident was observed with his/her breakfast meal in front of him/her, and was assisted by a nursing staff member.

Review of the resident’s care plans located in the medical chart, on 3/17/17 at 8:55 A.M., did not indicate the assistance needed for Activities of Daily Living (ADLs) including information on level of assistance needed for the resident related to bathing, dressing, and hygiene. Review of the Comprehensive Care Plan Record of Meetings, dated 3/9/17, indicated that a Quarterly meeting was held, and was attended by social services, activities and nursing staff. During an interview, on 3/17/17 at 8:55 A.M., Unit Manager (UM) #1 said that current care plans are located in the resident’s chart, and are reviewed at care plan meetings every 3 months, and with any changes.

During an interview, on 3/17/17 at 9:05 A.M. UM #1 said that he was unable to find the ADL care plan and that this information must have not been completed. During an interview, on 3/17/17 at 1:00 P.M., the Director of MDS said that ADL care plans are put in the clinical record for every new admission to the facility, and are completed for every resident.

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 record review and facility staff interview, the facility failed to accurately reconcile, transcribe and maintain physician orders, to ensure they included all current medication and treatment orders required for 2 residents (#9 and #11), in a total sample of 17 residents.

Findings include:

1. For Resident #9, the facility staff failed to provide the resident the necessary treatments, monitoring and medications due to discontinuing Physician orders [REDACTED]. Resident #9 was admitted to the facility 1/2017, with multiple [DIAGNOSES REDACTED]. Review of the Admission Data Set (MDS) Assessment, dated 1/23/17, indicated the resident had an indwelling urinary catheter and was totally dependent for bathing, grooming, and dressing. Review of the 2/2017 Physician order [REDACTED].

-[MEDICAL CONDITION]: [MEDICATION NAME] TTS (tight to shaft) #6 (changed 1/30/17)

– P.M.V. (Passy Muir Valve used to enable speaking) use _____ (blank) hours per day

– remove at bedtime (there was a written notation ‘as tolerated’)

– cough assist (stimulates a cough to help to mobilize secretions) inspiration positive pressure 30-35 centimeter(cm) water (H2O), expiratory pressure 35-40 cm H2O 4 times a day

– 21% cool mist with air compressor [MEDICAL CONDITION]

– [MEDICATION NAME] 20% mix with [MEDICATION NAME] 2.5/3 millimeters (ml) inhaled via nebulizer 3 times a day

– Finger stick blood sugar (FSBS) 4 times a day, and inject Humalog (U/100) (rapid-acting) insulin subcutaneously (SC) per sliding scale. The sliding scale was as follows:

If FSBS:

-201-250 give 2 units
-251-300 give 4 units
-301-350 give 6 units
-351-400 give 8 units
-401-500 give 10 units
-450-499 give 7 units
501 or greater call MD/NP

Recheck in 2 hours

If recheck continues to be greater than _______ (blank) Notify MD/NP Review of the 2/2017 Insulin Medication Record, indicated an entry for the resident to have a FSBS 3 times a day, not the 4 times a day as per the Physicians order, and to give Humalog insulin SC per the sliding scale. The entry was documented as completed from 2/1/17 through 2/15/17- 3 times a day, two times on 2/16/17, and once on 2/17/17. A written notation across the daily documentation area for FSBS was to discontinue (D/C) as of 2/17/17. The FSBS was also documented as completed at 11:30 A.M. on 2/18/17 & 2/19/17. No Physicians order was found during record review to discontinue the FSBS 4 times a day with sliding scale insulin coverage. Review of the printed 3/2017 (signed by a facility R.N. as reviewed 2/27/17) Physician orders, indicated the following incomplete and order discrepancies: -Change/clean inner cannula every 12 hours using clean technique ([MEDICAL CONDITION] the resident had did not have an inner cannula) -Oxygen (O2) at ___ (blank) Liters/Minute ____(blank) mist with ____ (blank) of O2 bled in via compressor (the resident was on 21% (room air) via cool mist air compressor at night and there was no order on the 3/2017 orders) -P.M.V. (Passy Muir Valve (used to enable speaking) use _____ (blank) hours per day – remove at bedtime ( there was no use time indicated) -Trach Type: [MEDICAL CONDITION] 7 (The resident no longer had a size [MEDICAL CONDITION] on 1/30/17 the physician had changed it to a [MEDICATION NAME] TTS (tight to shaft) #6). (there was no order on the 3/2017 for the cough assist treatment 4 times a day with required pressures) During record review, there was no 3/2017 documentation found or provided by facility upon the surveyor’s request to indicate that the cough assist treatment was provided 4 times a day, as ordered. -Acetylcyst Sol 20% (printed) [MEDICATION NAME] 2.5 milligrams (mg) (hand written) mix 3 milliliters (ml) (600 mg) with [MEDICATION NAME] and inhale via Nebulizer three times a day.

Review of interim Physician orders, dated 1/12/17, indicated an order to discontinue (D/C) [MEDICATION NAME] (sterile inhalation medication solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME] – [MEDICATION NAME][MEDICATION NAME]). A new order was written for the resident to receive -Mix Mucomist 20% with [MEDICATION NAME] 2.5mg/3ml three times a day. During an interview with the facility Respiratory Therapist (RT), on 3/22/17 at 9:55 A.M., she said that the [MEDICATION NAME] had been discontinued shortly after the resident was admitted . The [MEDICATION NAME] 20% with the 2.5mg [MEDICATION NAME] nebulizer treatment is what was ordered and was the treatment she provided when she was there. She further said that she worked 3 days a week at the facility, and when she was not there, the nurses provided the treatments. The RT also said that when she is there, she provides the cough assist treatments for the resident to help mobilize secretions, due to paralysis, he/she is unable to this.

-Finger-stick blood sugar (BS) 4 times/day at: 6 A.M., 11:30 A.M., 4:30 P.M., and 9:00 P.M. and inject SC Humalog(U/100) (rapid-acting) insulin per sliding scale:
-BS 61-200 give 0 units insulin SC
-BS 201-250 give 2 units insulin SC
-BS 251-300 give 4 units insulin SC
-BS 301-350 give 6 units insulin SC
-BS 351-400 give 8 units insulin SC
-BS 401-500 give 10 units insulin SC
>500 call M.D. 0 units insulin SC

Review of the 3/2017 Medication Administration Record [REDACTED]. Although there was a line through the documentation area on the MAR, there were two 6:00 A.M. BS results documented that would have required the administration of SC insulin: -3/14/17 BS 323 per the SC the resident should have received 6 units of Humalog insulin -3/17/17 BS 314 per the SC the resident should have received 6 units of Humalog insulin There was no documentation that any insulin coverage was provided for the 3/14/17& 3/17/17 documented elevated FSBS. During record review, there was no 3/2017 Insulin Medication Record form found or provided by the facility upon the surveyor’s request. During an observation of Resident #9, on 3/21/17 at 12:20 P.M., the resident was in bed with the head of the bed up approximately 80 degrees. The resident was conversant and had a 6.0 [MEDICAL CONDITION] in, with a P.M.V. valve in place. During an interview with the Assistant Director of Nurses (ADON), on 3/21/17 at 4:10 P.M., he said that there was no order to discontinue the FSBS and Humalog insulin per the sliding scale coverage orders. The order had been discontinued in error on 2/17/17. He further said that he had contacted the Physicians’ Assistant (PA) and the PA wanted the FSBS with sliding scale insulin coverage reinstated as it had not been discontinued. The ADON also said that he would review and clarify with the PA all of the orders that had missing and inconsistent information.

2. For Resident #11, the facility failed to reconcile the Physician orders [REDACTED]. Resident # 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the Admission MDS Assessment, dated 2/2/17, indicated the resident required extensive assist with bed mobility, transfer and bathing grooming and toilet use. Review of the readmission physician’s orders [REDACTED]. -Vitamin D 50,000- the order did not indicate form, route or frequency that the medication was to be provided -[MEDICATION NAME] (rapid acting) insulin with meals and at hour of sleep per sliding scale There was no order for the FSBS 4 times a day, nor the specific [MEDICATION NAME]sliding scale dosage to administer per FSBS level. During an interview with the ADON, on 3/22/17 at 12:40 P.M., he said that when a resident is readmitted to the facility from the hospital, the hospital discharge orders and previous orders are reconciled with the Physician, to ensure all required orders are in place. Further interview with the ADON, on 3/22/17 at 2:40 P.M., he said he had contacted the Physician Assistant to clarify the FSBS with [MEDICATION NAME] sliding scale insulin orders and vitamin D 50,000 order that were omitted/ incomplete on the 3/3/17 readmission orders [REDACTED]

Failed to provide 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 record reviews, observations and interviews, the facility staff failed to follow the Physician’s Orders for 4 sampled residents (#8, #10, #12 and #13), in a total sample of 17 residents.

Findings include:

1. For Resident #12, the facility staff failed to apply a urinary leg bag when the resident was out of bed, as planned. Resident #12 was admitted to the facility in 1/2016, with [DIAGNOSES REDACTED]. Review of the Nurse Notes, dated 3/26/16, indicated the resident was attempting to transfer himself/herself from the wheelchair to the toilet and he/she tripped on his/her urine bag and sat down. Review of the Occurrence Report, dated 3/26/16, indicated the resident sustained [REDACTED].M. and was found in a sitting position by his/her wheelchair. The report further stated that the resident tripped on his/her catheter bag while trying to transfer to the toilet. Further review of the Occurrence Report, indicated immediate actions taken after the fall was to remind staff to apply a leg bag to the resident upon rising. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/10/17, indicated a Brief Interview for Mental Status score of 10 out of 15 (moderate cognitive impairment). In addition, Section H0100 indicated that the resident utilized an indwelling catheter. Review of the Nurse Aide’s Information Sheet, undated, indicated that the resident is to have a leg bag applied when out of bed. During an interview, on 3/22/17 at 4:10 P.M., the Director of Nurses (DNS) said the resident should have had a urinary leg bag applied since he/she was out of bed.

2. For Resident #8, the facility staff failed to keep his/her heels up on a cushion when he/she was up in a wheelchair, as care planned Resident #12 was admitted to the facility in 4/2010, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 2/24/17, indicated in Section C1000, that the resident was moderately impaired for cognitive skills for daily decision making. Review of the Monthly Physician Orders, dated 3/1/17, indicated that the resident’s heels needed to be elevated on an up cushion while in bed and in the gerichair. Review of the Nurse Aide’s Information Sheet, undated, indicated the resident’s heels be placed on up cushion when in bed and in the chair. During an observation, on 3/21/17 at 12:30 P.M., the surveyor observed the resident sitting in a gerichair, in the unit dining room. The resident was being fed lunch by a staff member. The resident’s feet were resting on the footrests of the gerichair and the footrests were in the down position. The heels were not elevated, and there was no up cushion noted on the footrests, as care planned. During an observation, on 3/22/17 a 9:10 A.M.,the resident was in the unit small dining room and was sitting in a gerichair. The footrests of the gerichair were down, the heels were resting on the footrests and there was no up cushion noted on the footrests, as care planned. During an interview, on 3/22/17 at 9:25 A.M., Unit Manager #2 said the resident’s heels were not elevated on an up cushion while in the gerichair, as care planned.

3. For Resident #10, the facility staff failed to follow the plan of care relative to adhering to the physician prescribed diet order and allergy information. Resident #10 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the Physician’s Orders, dated 3/2017, signed by the Nurse Practitioner on 3/3/17, indicated an order for [REDACTED].#13 had an allergy to lactose. Review of the Quarterly MDS Assessment, with an ARD of 2/17/17, indicated that Resident #10 exhibited unclear speech, was rarely/never understood, was severely cognitively impaired, was totally dependent on staff for eating and received a mechanically and therapeutically altered diet. Review of the resident’s meal ticket, dated 3/17/17 for lunch, indicated the diet for Resident #10 as low lactose, ground with nectar thick liquids. Further review of the meal ticket, indicated for the resident’s lunch tray to include: soft, cooked, ground sliced carrots (received sliced carrots), and a serving of moistened cookies (received a slice of Boston Cream pie). The meal ticket also included dislikes as no dairy products. During an interview, on 3/17/17 at 12:20 P.M., Certified Nursing Assistant (CNA) #3 said that the resident ate almost everything on the lunch tray, including the dessert. During a meal observation, conducted on 3/22/17 at 11:55 A.M., the surveyor observed Resident #10 seated in the dining room. The resident had his/her lunch meal in front of him/her. The resident was observed to have 2 open and empty containers of 1/2 and 1/2 dairy creamers on his/her meal tray, which had been used in the coffee, and a container of cut up mixed fruit. Review of the resident’s meal ticket, dated 3/22/17 for lunch, indicated the diet for Resident #10 as low lactose, ground with nectar thick liquids. Further review of the ticket, indicated the resident’s lunch tray to include: choice of ground fruit (received cut up/cubed mixed fruit), condiments (did not specify) and includes dislikes as no dairy products. During an interview, on 3/22/17 at 11:55 A.M., Nurse #1 said that meal trays are checked for accuracy in the kitchen. Nurse #1 further said that the resident meal trays are also checked by the nurse for accuracy when the meal is served. During an interview, on 3/22/17 at 11:57 A.M., Unit Manager (UM) #1 said that that Resident #10 should not have received the dairy items on his/her meal trays.

4. For Resident #13, the facility staff failed to follow the Physician’s Orders relative to applying TED stockings (compression stockings) daily, as ordered. Resident #13 was admitted to the facility in 2/2015, with [DIAGNOSES REDACTED]. Review of the Nurse’s Notes, dated 12/21/16, indicated that Resident #13 was noted to have mild [MEDICAL CONDITION] to his/her left foot. The Nurse Practitioner (NP) was updated, evaluated the resident, and ordered lab work and TEDS to be applied to the resident’s lower extremities daily. Review of the Cardiovascular Care Plan, initiated 12/21/16, indicated that Resident #13 had an alteration in cardiovascular status with symptoms of bilateral lower extremity [MEDICAL CONDITION] (lower limb swelling), with interventions to include: apply TEDS as ordered. Review of the Nurse Aide’s Information Sheet, undated, indicated that the resident is to have TEDS applied in the morning and off at bedtime (HS). Review of the Quarterly MDS Assessment, with an ARD of 3/3/17, indicated that Resident #13 exhibited severe cognitive impairment and required extensive assistance of 1 staff for dressing and personal hygiene. Review of the Physician’s Orders, dated 3/2017, signed by the NP on 3/6/17, indicated an order to apply TEDS to bilateral lower extremities (BLE) at 6:00 A.M. and remove at bedtime.

Review of the Treatment Record, dated 3/2017, indicated an order to apply TEDS to BLE at 6:00 A.M. and remove at HS. Further review of the Treatment Record, indicated that the treatment was completed from 3/9/17 through 3/21/17. On 3/22/17 at 10:50 A.M., the surveyor observed Resident #13 seated in a wheelchair, in the activity room, where there was music playing. The resident was dressed and was wearing sandals with no TED stockings in place, as ordered. On 3/22/17 at 11:55 A.M., the surveyor observed Resident #13, seated in a wheelchair, in the dining room. The resident had his/her lunch meal in front of him/her. The resident was wearing sandals with no TED stockings in place, as ordered. On 3/22/17 at 2:50 P.M., the surveyor observed Resident #13, seated in a wheelchair, in the activity room. The resident was wearing sandals with no TED stockings in place, as ordered. During an interview, on 3/22/17 at 3:00 P.M., CNA #6 said that Resident #13 requires assistance with his/her care. He further said that the resident wears TED stockings, as needed, for swelling. During an interview, on 3/22/17 at 3:05 P.M., CNA #5, who was assigned to Resident #13 on this date, said that Resident #13 wears TED stockings as he/she requests. During an interview, on 3/22/17 at 4:10 P.M., Nurse #6 said Resident #13 was not wearing TED stockings, as ordered.

Failed to develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, for one sampled resident (#9) out of a total sample of 17 residents, the Facility failed to document that the resident and family (care givers) received education related care needs such as insulin administration , Fingerstick Blood sugars (FSBS)monitoring and respiratory care to ensure that they were ready and able to provide the care required upon discharge.

Findings include:

Resident #9 was admitted to the facility 1/2017 with multiple [DIAGNOSES REDACTED]. Review of the Admission Data Set (MDS) assessment dated [DATE], indicated the resident had an indwelling urinary catheter and was totally dependent for bathing, grooming, and dressing. Review of a Physician Assistant’s (PA) progress note dated 2/1/2017 indicated to start education with family members for [MEDICAL CONDITION] care and all that entails. Should also teach family members how to do injections for diabetes management and [MEDICATION NAME] for [MEDICAL CONDITION]. During interview with the Assistant Director of Nurses (ADON) on 3/21/17 at 11:45 A.M. he said there should be a form that the facility uses kept in the Medication Administration Record [REDACTED]. Surveyor informed the ADON no education form was found for Resident #9 and family members in preparation for discharge home regarding care needs. During interview with the ADON on 3/21/17 at 4:10 P.M. he said that there was no education form found for Resident #9. However, he said he had discussed with nursing staff and the resident’s family member regarding education that had been provided. He said that nursing staff said that diabetes teaching,straight catheterization and suctioning education had been provided and that on 3/21/17, training was provided regarding FSBS and insulin. He further said that the nursing staff had compiled documentation on 3/21/17 that included what education/training was provided. Although according to the ADON’s discussion with facility staff the facility had provided training to the resident and family members (care givers) there was no documentation available prior to surveyor inquiry. There was no documentation that described what specific education was provided and what if any further education needs remained, to ensure all were ready and able to provide the care required upon discharge .

Failed to maintain 15 months of resident assessments in the resident's active clinical record.

Based on record review and facility staff interview, the facility failed to maintain the required 15 months of Minimum Data Set (MDS) Assessments in the active clinical record, that is accessible to all professional staff members, who need to review the information. The limited accessibility affected all the MDS Assessments completed in the facility.

Findings include:

During an interview with the Director of Nurses Services (DNS), on 3/16/17 at 7:30 A.M., (day one of the recertification survey) surveyors inquired about the medical record system in use by the facility, to gain access to the necessary documents needed for review during survey. The DNS said that the facility maintains a paper medical record for all residents with the exception of the MDS Assessments. It was explained that they utilize computerized software for the completion of the MDS, and the MDS Assessments are stored electronically. She further said that they are not in the printed medical record. She informed the surveyors that they would need to ask the DON or MDS Director to print the MDS Assessments they needed to review, as there is limited access. During an interview, with the DNS on 3/21/17 at 2:00 P.M., when asked about the access to the MDS Assessments, she said that the MDS Director, facility dietician and Social Worker can enter data into the MDS Assessments and that she can preview the MDS Assessment. She said that the facility staff nurses did not have access to the computerized MDS. When asked how staff would access the MDS, she said they would have to call the DNS or MDS Director to have the documents printed.

During an interview with the MDS Director, on 3/22/17, she said that she completes the MDS Assessments in the computer except for the sections completed by the Social worker, Activities Director and the Dietician. She further said that all of the MDS Assessments are stored in the computer, and she was not sure if the DNS had access to the electronic MDS Assessments. She further said that the nurses on the resident units do not have access, and that they do not use the MDS Assessments. During an interview, with the DNS on 3/22/17 at 2:00 P.M., she said that there is not access to the MDS Assessments 24 hours a day, as it is limited to who has access to the computerized system.

Failed to assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.

Based on observations and interviews, the facility staff failed to maintain good personal hygiene related to nail care, for 1 sampled resident (#13), in a total of 17 sampled residents.

Findings include:

Resident #13 was admitted to the facility in 2/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/3/17, indicated that Resident #13 exhibited severe cognitive impairment and required extensive assistance of 1 staff for dressing and personal hygiene.

On 3/16/17 at 8:00 A.M., during the initial tour, the surveyor observed Resident #13 seated in a wheelchair. The resident was dressed and was wearing glasses. The resident was observed to have long fingernails that were curling and discolored.

On 3/22/17 at 10:50 A.M., the surveyor observed the resident, seated in a wheelchair, in the activity room. The resident was dressed and was holding a maraca while music was playing. The surveyor observed the resident’s nails to be very long and discolored.

On 3/22/17 at 11:55 A.M., the surveyor observed the resident seated in the dining room, with a lunch tray in front of him/her. The resident’s nails were observed to be very long, and discolored. During an interview, on 3/22/17 at 12:08 P.M., Certified Nursing Assistant (CNA) #5 said that nail care is completed once a week and includes cutting the nails. She said that the resident’s nails are cleaned every day, but further said that she did not clean Resident #13’s nails today.

During an interview, on 3/22/17 at 12:10 P.M., Unit Manager (UM) #1 said that Resident #13’s nails were not clean, and that he would expect the resident’s nails to be short and clean. He further said that the CNAs are responsible for resident nail care.

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 record review, observation and interview, the facility staff failed to provide adequate supervision and services to prevent accidents and hazards for 2 sampled residents (#12, #3) out of a total sample of 17 residents. In addition, the facility failed to provide an environment free from accident hazards in one area of the facility.

Findings include:

1. For Resident #12, the facility staff failed to implement interventions and adequate supervision after the resident experienced three falls in order to help reduce the incidence of falls and injury. Resident #12 was admitted to the facility in 1/2016, with [DIAGNOSES REDACTED]. Review of the Fall Prevention Program, with a revision date of (8/2011), indicated that each resident will have an individual assessment and care plan which will address their specific needs related to fall risk. Review of the facility Accident/Incident Reporting Policy, dated (4/2013), indicated that the resident’s care plan will be initiated or updated with appropriate interventions after an accident or incident. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 3/10/17, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderate cognitive impairment).

a. Review of the Nurse’s Notes, indicated that the resident had a fall on 3/26/16 at 3:15 P.M Review of the Occurrence Report, dated 3/26/16, indicated that the resident had a fall due to tripping on his/her catheter bag while transferring himself/herself onto the toilet. The intervention put in place after the fall was to remind the resident to call for assistance for transfers and to remind staff to apply urinary leg bag when out of bed.

b. Review of the Nurse’s Notes indicated that the resident had a fall on 7/6/16 and to review the Situation Background Assessment Recommendation (SBAR) notes for further information. Review of the SBAR, dated 7/6/17, indicated the resident self reported to the Certified Nurse Aide (CNA) at 12:35 P.M., that he/she was in the bathroom and had fallen and had gotten himself/herself back into bed. In addition, the resident was noted to have a fever, vomited twice and was experiencing slurred speech. Review of the Occurrence Report, dated 7/6/16, indicated that after the fall, the resident was transferred to the hospital and admitted with [DIAGNOSES REDACTED]. Upon return from the hospital, there was no new intervention put in place for the fall.

c. Review of the Nurse’s Notes, dated 7/18/16, indicated the resident was standing at the bathroom door at 3:10 A.M., with his/her Foley catheter stuck under the door, and was witnessed by staff member falling onto his/her right knee and sustaining a skin tear to the right knee. Review of the Occurrence Report, dated 7/18/16, indicated that there was no new intervention put into place after the fall.

d. Review of the Nurse’s Notes, dated 9/7/16, indicated the resident was heard screaming at 11:30 P.M., and was found lying flat on his/her back in the bathroom. The resident could not move his/her left leg and was transported to the hospital Review of the Incident Report Form, dated 9/12/16, indicated that the resident sustained [REDACTED].

e. Review of the Nurse’s Notes, dated 1/15/17, indicated that the resident was in the bathroom at 12:15 P.M., and had pulled the call light to report that he/she had slipped and fallen while attempting to transfer onto the toilet from his/her wheelchair. Review of the Occurrence Report, dated 1/15/17, indicated that the resident had sustained a fall in the bathroom while attempting to self transfer from wheelchair onto toilet. The report was incomplete and no new interventions were documented. During an observation, on 3/22/17 at 11:00 A.M., the resident was awake and resting in bed.

The resident responded to simple questions. A floor mat was noted on next to the bed from the window side. The resident’s bed was in the low position. The call light was within the resident’s reach and the motion sensor was in place and activated. During an interview, on 3/22/17 at 2:15 P.M., the Director of Nurses (DNS) said that falls that occurred on (7/6/16, 7/18/16 and 1/15/17), did not have new interventions put in place after the falls occurred. The DNS said the resident should have not been left alone in the bathroom on (1/15/17), when he/she sustained a fall as the resident was a high fall risk. She said she was aware the resident had a history of [REDACTED].

2. For Resident #3, the facility staff failed to ensure the resident received adequate supervision to prevent accidents relative to the resident putting non-edible items in his/her mouth, which had a potential for resident harm. Resident #3 was admitted to the facility in 3/2010, with [DIAGNOSES REDACTED]. Review of the Risk of Injury Secondary to Ingestion of Non-Food Item Care Plan, initiated 2/9/16 and updated 1/19/17, indicated that the resident had ingested non-food items including chewing on clothes and eating paper/tissues. The interventions that were in place at this time included: notify the physician, observe for any adverse reaction, vital signs as ordered and as needed, observe the resident in areas where potential to ingest non-food items could occur.

Review of the West Central Family and Counseling Progress Note, dated 1/27/17, indicated the resident was noted to put napkins and towels in his/her mouth. Review of the Annual MDS Assessment, with an ARD of 3/10/17, indicated that Resident #3 had unclear speech, was rarely understood or understands, exhibited severe cognitive impairment, required extensive assistance of 2 staff for transfers, required supervision of 1 staff with eating, and received a mechanically altered diet. On 3/17/17 at 2:45 P.M., the surveyor observed Resident #3 lying in bed with his/her eyes open. The resident was observed to be chewing on a clear small plastic cup. The surveyor observed another clear small plastic cup on the resident’s bed near his/her left side. During an interview, on 3/17/17 at 2:45 P.M., Nurse #2 said that Resident #3 had a behavior of chewing on things. The surveyor observed Nurse #2 remove the small plastic cup from Resident #3’s mouth. Nurse #2 said that the item Resident #3 was chewing on was a medication cup. The surveyor observed a thick milky white liquid to be inside the bottom edges of the medication cup that Nurse #2 had removed. Nurse #2 said that the resident needs to be supervised when given his/her medications, and that the resident sometimes grabs items to chew on. The surveyor observed Nurse #2 also remove the other medication cup from the resident’s bed.

On 3/22/17 at 10:50 A.M., the surveyor observed Resident #3 in the Activity Room, seated with other residents in a circle, facing a member of activities staff. The resident was seated in a wheel chair, and was observed by the surveyor, taking pieces off of a styrofoam cup and putting them into his/her mouth. The surveyor observed that approximately 1/4 of the styrofoam cup was missing. The surveyor observed the activities staff member remove the styrofoam cup from Resident #3. During this time, the surveyor was able to observe small pieces of white styrofoam present in the resident’s mouth. Nurse #1 entered the activity room at this time, and the surveyor observed Nurse #1 remove pieces of white styrofoam from the resident’s mouth. The resident was observed to be coughing during the time that Nurse #1 was attempting to remove the items from his/her mouth. During an interview, on 3/22/17 at 11:05 A.M., Nurse #1 said that he was able to take 2 larger pieces and 1 smaller piece of styrofoam out of Resident #3’s mouth. He further said that he was not aware if the resident swallowed anything.

3. The facility failed to ensure the environment was free of accident hazards related to securely storing cleaning chemicals in a resident accessible area. During the environmental tour of the facility, on 3/16/17 at 1:35 P.M., the facility Housekeeping Managers office was observed with the Housekeeping Director. The office was located in the hallway to the left of the main lobby, across from a rehabilitation resident treatment room, and a few doors down from the business office where residents went to access their Personal Needs Accounts (PNA). Additionally, the facilities main dining room, where residents travel to and from to eat meals and also attend various activities, is located at the other end of the hallway. The Housekeeping Director was observed to access the office by pushing on the door with her hand as the door was not completely closed. On one side of the office, there was a multi-tier shelving unit that had housekeeping supplies including multiple types of cleaning chemicals stored on the shelves. During an interview, with the facility Housekeeping Manager on 3/16/17 at 1:35 P.M., she said that cleaning supplies were stored in a shed outside the building. She said that she stocked the shelves in her office with the cleaning chemicals and supplies for the facility housekeepers’ to access and stock their cleaning carts. On 3/17/17 at 10:20 A.M., the Housekeeping Managers office door was observed to be open with no one inside.

On 3/22/17 at 7:25 A.M., the Housekeeping Managers office was observed to have the door wide open, with no one inside. The metal shelving unit, located in the office, was observed to be stocked with multiple plastic bottles of various cleaning chemicals such as Eliminator Concentrated Odor Neutralizer, 44 ACE Disinfectant Cleaner, Tru Clean Liquid Cleaner and gallon of Clorox Bleach. On 3/22/17 at 8:50 A.M., with the Director of Nurses Services (DNS) present, the Housekeeping Directors office was observed to be open and the door unlocked. The DNS said that the door is supposed to be locked due to the storage of chemicals and it is not. She further said that residents use the hallway unsupervised as it is adjacent to the lobby. They also pass through the hallway to access their PNA accounts from the business office and rehabilitative services across the hall.

Failed to post nurse staffing information/data on a daily basis.

Based on observations and interview, the facility staff failed to post the daily staffing and census information, as required.

Findings include:

On 3/21/17 at 4:30 P.M., the surveyor observed the daily staffing and building census information sheet, located in the lobby area, on the reception desk, indicating information for Thursday, 3/16/17. On 3/22/17 at 7:40 A.M., the surveyor observed the daily staffing and building census information sheet, located in the lobby area, on the reception desk, indicating information for Thursday, 3/16/17. On 3/22/17 at 2:40 P.M., the surveyor observed the daily staffing and building census information sheet, located in the lobby area, on the reception desk, indicating information for Thursday, 3/16/17.

During an interview, on 3/22/17 at 4:20 P.M., the Administrator said that there was some confusion about who is responsible for updating the information on the daily staffing and building census sheet therefore the information was not updated.

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

Based on observations and staff interviews, the facility failed to maintain and/or assure sanitary conditions during the preparation, distribution and service of food. Staff failed to ensure the proper cleaning and sanitizing of equipment as well as ensuring that nonfood-contact surfaces were kept free of an accumulation of food residue and dust.

Findings include:

During observations of the kitchen, on 3/16/17 at 8:00 A.M., and with the Food Service Director (FSD) on 3/22/17 at 1:40 P.M., the following was observed:

1. A large white scoop was positioned on top of the ice machine, not within a housing compartment, and open to contamination.

2. A large amount of dust was noted on all external vents of the air conditioning units that were located:

a.) across from the ice machine,
b.) over the cold preparation table and,
c.) near the clean end of dish machine.

On 3/22/17, the surveyor observed that the air conditioner unit, located near the clean end of the dish machine, was on and was blowing cold air. The air conditioner was positioned directly over a rack that housed clean dishes.

3. The cook top range had large amounts of black thick residue around the burners and on the back splash

. 4. The pot and pan rack, located next to the convection oven, had dust on the shelving. The shelving had brown and red discoloration noted and was observed to be tacky to the touch. 5. The electric cord, that connects to the plate warmer, located adjacent to the steam table, was dust laden. The plate warmer was observed to be uncovered and plates were visible.

6. On 3/22/17 at 1:40 P.M., the dish machine temperatures were observed to at: Wash Cycle = 90 degrees Fahrenheit (F) / Rinse Cycle = 110 degrees F . During an interview at this time, Diet Aide #1 (who was operating the dish machine at the time of the observation), said that he was not sure what the dish machine temperatures should be running at. During an observation, with the FSD at 1:50 P.M., the Wash Cycle = 100 degrees F/ Rinse Cycle = 120 degrees F.

During an interview, on 3/22/17 at 1:50 P.M. and 2:00 P.M., the FSD said that the minimum temperature for the dish machine is 120 degrees F for the wash and the rinse cycle. He further said that the air conditioning units were dirty and needed to be cleaned, and that he saw the dust located on the electrical cord connecting to the plate warmer. The FSD said that the pot racks needed to be cleaned.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy of dosage on 2 of 3 units observed.

Findings include:

1. During an inspection of the Unit 4 medication A cart, on [DATE] at 8:30 A.M., 3 packets of Phos- Pak (phosphorous medication) were found with an expiration date of ,[DATE]. In addition, an unopened Novolog (fast-acting insulin) pen for a specific resident was found in the cart. Unopened insulin pens need to be refrigerated until put into use. During an interview, on [DATE] at 8:35 A.M., Nurse #3 said the Phos-Paks were expired and the unopened Novolog Insulin should have been stored in the refrigerator.

2. During an inspection of the Unit 3 medication A cart, on [DATE] at 2:50 P.M., the following item was found: – One unopened Humalog (fast acting insulin) pen for a specific resident During an interview, on [DATE] at 2:35 P.M., Nurse #4 said the unopened Humalog pen should have been refrigerated.

3. During an inspection of the Unit 3 medication room refrigerator, on [DATE] at 10:30 A.M., one vial of Tubersol (vaccine used in [DIAGNOSES REDACTED]. Tubersol vaccine once opened, needs to used within 30 days or discarded. During an interview, on [DATE] at 10:35 A.M., Unit Manager (UM) #1 said the Tubersol Vaccine was expired.

4. During an inspection of the Unit 3 treatment cart, on [DATE] at 10:40 A.M., one opened jar of Triamcinolone Acetonide 1% ointment (used to treat skin inflammation) for specific resident, was found with an expiration date of ,[DATE]. During an interview, on [DATE] at 10:45 A.M., UM #1 said the jar of Triamcinolone Acetonide 1% ointment was expired.

Failed to have a program that investigates, controls and keeps infection from spreading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility staff failed to follow proper infection control practices for the prevention and spread of infection for 3 sampled residents ( #2, #8, #9) in a total sample of 17 sampled residents and for 3 non-sampled residents (NS #1, NS #2, NS #3) out of 8 applicable non-sampled residents, in a total sample of 17 sampled residents.

Findings include:

1. For Resident #2, the facility staff failed to follow infection control practice by placing soiled items, on the floor, in a resident’s room. Resident # 2 was admitted to the facility in 10/2012, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/3/17, indicated in Section C1000 that the resident was moderately impaired for cognitive skills for daily decision making. During an observation, on 3/22/17 at 9:10 A.M., the surveyor observed a soiled incontinence pad and towel on the floor, between the resident’s bed and night stand. The resident was not in his/her room. During an observation, on 3/22/17 at 9:30 A.M., the surveyor observed the soiled incontinence pad and towel on the floor, between the resident’s bed and night stand. During an interview, on 3/22/17 at 9:35 A.M., Certified Nurse Aide (CNA) #1 said the incontinence pad and towel should not be lying on the floor, and he picked the items up to discard them. During an interview, on 3/22/17 at 5:00 P.M., the Director of Nursing Services (DNS) said the soiled pad and towel should not have been on the floor as it is an infection control concern.

2. For Resident #8, the facility staff failed to follow facility policy when performing a Clean Dressing treatment.

Review of the facility Procedure for Clean Dressing Technique Policy, undated, indicated hands must be washed after every glove change during the procedure. Resident # 8 was admitted to the facility in 4/2010, with [DIAGNOSES REDACTED].

Review of the Quarterly MDS Assessment, with an ARD of 2/24/17, indicated in Section C1000, that the resident was moderately impaired for cognitive skills for daily decision making Review of the Monthly Physician Orders, dated 3/1/17, indicated an order to provide treatment to the left gluteal fold: normal saline wash, pat dry, apply Santyl (a [MEDICATION NAME] ointment) and cover with foam dressing daily, on the 7-3 shift. During an observation of the treatment to the left gluteal fold, on 3/22/17 at 1:15 P.M., the surveyor observed Nurse #5 remove the old dressing and discard it in an appropriate disposal bag. Nurse #5 removed her gloves and applied a new set of gloves. Nurse #5 changed her gloves 5 times throughout the procedure, but never washed her hands with the alcohol-based hand rub that was present and within her reach. During an interview, on 3/22/17 at 3:30 PM., the DNS said that Nurse #5 should have washed her hands every time she changed her gloves during the dressing change procedure. 3. The facility staff failed to cleanse their hands between medication pass for NS #1 and NS #2. NS #1 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. NS #2 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. During an observation, on 3/17/17 at 8:00 A.M., the surveyor observed Nurse #5 administer NS #1 his/her medications. After the medication pass was complete, Nurse #5 returned to the medication cart and prepared medications for NS #2 and administered the medications. Nurse #5 never cleansed her hands before preparing medications for NS #2. Review of the facility Medication Administration and Documentation-General, Policy #PHNE69, undated, indicated the Infection Control protocols must be maintained at all times. Further review of the Medication Administration and Documentation- General Policy, indicated that the licensed nurse washes hands at the beginning of medication pass and in between each resident, using soap and water or alcohol-based cleanser. During an interview, on 3/22/17 at 4:00 P.M., the DNS said Nurse #5 should have washed her hands prior to preparing medications for NS #2.

4. For NS #3, the facility staff failed to perform infection control practice when preparing medications for resident administration. NS #3 was admitted to the facility in 10/2016, with [DIAGNOSES REDACTED]. During an observation, on 3/17/17 at 8:20 A.M., Nurse #3 was observed preparing NS #3 medications for administration. The surveyor observed Nurse #3 place the resident’s medications into a bag to prepare to crush them. Nurse #3 proceeded to remove one Multivitamin tablet from the bag with her ungloved hands and placed the Multivitamin aside so as not to crush the tablet. Review of the Medication Administration and Documentation- General Policy, #PHNE69, undated, indicated that the licensed nurse maintains medical aseptic technique during the medication pass. During an interview, on 3/17/17 at 8:30 A.M., Nurse #3 said she should have worn gloves to remove the Multivitamin from the bag.

5. For Resident #9, the facility failed to ensure transmission based contact precautions were maintained, as required, to prevent the spread of infection. Review of the undated facility policy and Procedure for contact precautions included the following: Use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident care items. Resident #9 was admitted to the facility 1/2017, with multiple [DIAGNOSES REDACTED]. Review of the Admission Data Set (MDS) Assessment, dated 1/23/17, indicated that the resident had an indwelling urinary catheter and was totally dependent for bathing, grooming, and dressing. During the initial tour of the resident’s unit, with the Assistant Director of Nurses (ADON) on 3/16/17 at 8:30 A.M., the ADON identified Resident #9 as being on Contact Precautions for the presence of Methicillin Resistant Staphylococcus Aureus (MRSA) in the nares and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) in the urine.

Observation of the resident’s room, on 3/16/17 at 8:30 A.M., revealed a Stop sign outside the room, alerting visitors and staff to see the nurse before entering the room. There was a hanging holder, with divided compartments, that held the personal protective equipment (PPE) such as gloves and yellow precaution gowns, to be put on as required prior to entering the resident’s room. There was a crinkled up yellow gown behind the medication cart stuffed behind the handrail outside the resident’s room. The ADON picked it up and said it should not be there, and threw it in the step can inside the resident’s room, to the right of the doorway. He then proceeded wash his hands before continuing with the tour. Review of the Physicians (MONTH) orders signed 3/10/17, indicated the resident was on contact precautions for MRSA in the nares and VRE in the urine. During an observation, on 3/21/17 at 10:40 A.M., Nurse #3 entered Resident # 9’s room without putting any PPE on. Nurse #3 was observed to be leaning in toward the resident, resting her forearms on the over-bed table. The over-bed table was across the bed in front of the resident. The resident’s head of the bed was up at approximately 80 degrees. The nurse was then observed to administer medication from a soufflé cup into the resident’s mouth. During an interview with Nurse #3 at 10:45 A.M., after she exited the room, she said the resident was on Contact precautions for MRSA and that she does not wear a gown or gloves unless she is bathing or suctioning the resident, and then she wears PPE.

During an interview with the ADON on 3/21/17 at 10:50 A.M., he said that the stop sign is posted to alert visitors and staff to come and see the nurse to find out what type of PPE is needed. He further said that with contact precautions, they are to wear a gown and gloves always before entering the resident’s room/residents environment. During an observation on 3/21/17 at 12:10 P.M., CNA #7 entered Resident #9’s room, carrying a meal tray. The CNA was observed to place the tray on the over-bed table, that was across the bed in front of the resident. The CNA did not have any PPE on. The resident was observed to have his/her eyes closed. The CNA told the resident that lunch is here and proceeded to set up the tray for the resident. During an interview with CNA #7, after she exited the room, she said she was on orientation. When the surveyor asked her what the stop sign outside the resident’s room was for, she said that you had to check with the nurse before going in the room and to put on personal protective equipment.

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 observation, record review and interview, the facility staff failed to maintain an accurate medical record for one sampled resident, (#4), in a total sample of 17 residents.

Findings include:

Resident #4 was admitted to the facility in 8/2016, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 2/1/17, indicated a Brief Interview for Mental Status indicated a score of 15 out of 15 (cognitively intact).

During an observation, on 3/16/17 at 8:50 A.M., the resident was lying in bed, turned onto his/her left side, and had a breakfast tray resting on his/her overbed table.

The tray was within his/her reach. Review of the Comprehensive Care Plan#5 Activities of Daily Living (ADL) Function/Rehab Potential, with an updated date of 2/18/17, indicated the resident requires one assist for dressing, bathing and hygiene.

Review of the Nursing Flow Sheet, dated 3/2017, indicated the resident was dependent for Bathing, Grooming and Dressing. During an interview, on 3/17/17 at 7:45 A.M., Certified Nurse Aide #2 said the resident is independent for eating and is dependent for bathing, hygiene and dressing. During an interview, on 3/17/17 at 10:00 A.M., Unit Manager #2 said the resident’s care plans for bathing, hygiene and dressing were incorrect in indicating assist of one, and the care plans needed to be revised to reflect current plan of care.

Eliot Center for Health & 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 – Eliot Center for Health & Rehabilitation

Inspection Report for Eliot Center for Health & Rehabilitation – 03/22/2017

Page Last Updated: August 21, 2018

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