Parsons Hill Rehabilitation and Health Care Center

Parsons Hill Rehabilitation & Health Care Center

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

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About Parsons Hill Rehabilitation & Health Care Center

Parsons Hill Rehabilitation & Health Care Center is a for profit, 162-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Worcester, Leicester, Millbury, Shrewsbury,  Holden, Sutton, Spencer, Grafton, Oxford, Charlton, Northborough, Westborough, Northbridge, Webster, Clinton, and the other towns in and surrounding Worcester County, Massachusetts.

Parsons Hill Rehabilitation & Health Care Center
1350 Main St,
Worcester, MA 01603

Phone: (508) 791-4200
Website: http://www.athenanh.com/ma_parsons_hill.aspx

CMS Star Quality Rating

Parsons Hill Rehabilitation & Health Care CenterThe 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, Parsons Hill Rehabilitation & Health Care Center in Worcester, Massachusetts received a rating of 1 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 3 out of 5 (Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against Parsons Hill Rehabilitation & Health Care Center

The Federal Government fined Parsons Hill Rehabilitation & Health Care Center $103,740 on 05/19/2016 and $10,359 on 10/28/2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Parsons Hill Rehabilitation & Health Care Center committed the following offenses:

Failed to allow residents to easily view the results of the nursing home's most recent survey.

Based on observations and staff interviews, the facility failed to post the results of the most recent survey and the plan of correction.

Findings include:

On 1/4/16 at 8:45 A.M., the surveyor observed a white binder located in the lobby with a notice directing visitors and residents to review the previous survey results within the white binder and in the binders located on the resident units. The surveyor reviewed the contents of the white binder located in the lobby and the binders located on two resident units, and observed that the current survey results and plan of correction where not present in the binders. During interview, on 1/4/16 at 8:45 A.M., the Director of Nurses said the last survey should be in the binders.

Failed to determine if it is safe for the resident to self-administer drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to assess one resident (#9), prior to allowing the resident to self-administer a medication,out of total sample of 24 residents.

Findings include:

Resident #9 was admitted to the facility in 3/2009, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 10/25/16, indicated a Brief Interview for Mental Status (BIMS), score of 6 out of 15(severe cognitive impairment).

During an observation, on 1/5/17 at 9:20 A.M., the resident was sitting in his/her room in a wheelchair alone, and was self-administering a [MEDICATION NAME] Inhaler (steroid medication to open airways in the lungs to improve breathing).

Review of the facility Self-Administration of Medications Policy, dated (July (YEAR)), indicated a Self-Administration of Medications Informed Consent and Evaluation needed to be completed prior to a resident self-administering medications. Review of the medical record, indicated there was no Self-Administration of Medications Informed Consent and Evaluation completed. Review of the medical record, indicated there was no physician order for [REDACTED].>During an interview, on 1/5/17 at 11:10 A.M., the Assistant Director of Nurses (ADON) said there was no Self-Administration of Medications Informed Consent and Evaluation form in the medical record.

Failed to provide housekeeping and maintenance services.

Based on observation,environmental tours and staff interview the facility staff failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, homelike and comfortable interior throughout the facility including resident units, resident rooms window blinds/shades, shower rooms tile and grout, air conditioning(A/C) units and common areas throughout the facility.

Findings include:

Environmental tours on 1/4/17 at 10:45A.M., 1:15 P. M., 3:45PM. with the Facility Plant Manager, Assistant Director of Nurses(ADON) and the Director of Nurses(DON) the following observations were made: Burncoat unit-
-Room 19 missing vertical blind slats on the window blinds -Room 27 bathroom vent had dust build up -Resident bathroom located in the hallway outside soiled linen room
– radiator wall unit (approximately. 2 feet long) front cover unattached and on floor next to unit – no toilet paper holder, toilet paper roll sitting on top of the sink
-Day room air conditioner wall unit contained dust build up on the vents
-Day room radiator under the window had partially unattached cover
-Clean supply room contained an eye wash station that was missing protective caps
-small room with partial door had signage posted on outside wall identifying the room as a kitchenette and eye wash station. During observation, the room contained shelves with blankets and linen, and did not contain a kitchenette or eye wash station TCU unit-
-Room 5 was missing 2 vertical slats on window blinds -Shower room back wall tiles discolored with darkened grout -Adhesive foam approximately ¼ inch thick pieces adhered on side wall of shower approximately 4 by 4
-Room 02 was missing 4 vertical slats on window blinds
-Room 01 was missing 3 vertical slats on window blinds
-Air conditioner ceiling unit across from the dirty utility room was blowing out air through dusty vents
-Air conditioner wall unit between rooms 7 & 8 was blowing out air through dusty vents
-Air conditioner wall unit outside room 21 had dust build up on vents
-Air conditioner unit outside day room across from soiled linen room had dust build up on the right vent and was missing a vent cover on the left side
-Air conditioner wall unit across from room 32 had dust build up on the vents Vernon unit- -Room 18 was missing 3 vertical slats for window blinds
-Room 14 was missing 6 vertical slats for window blinds
-Shower room had soap film on the tiles, mixing valve and back wall, and contained discolored darkened grout between the tiles
-Air conditioner ceiling unit across from central supply had dusty vents/filters Greendale unit-
-Resident call bell light panel on nurses station on the back wall was misaligned from resident room numbers
-Small shower room grout was discolored darkened.
In addition, the small shower room contained 2 horizontal grab bars, each with 1 cap that covered the attachment hardware, each cap was dislodged, exposing the hardware
-Air conditioner ceiling unit outside resident rooms 4 & 5 had vents with dust build up
-Day/dining room ceiling air conditioner unit was missing right side vent cover and the left side vent filter had dust build up Tatnuck unit
-Day/dining room had air conditioner unit in the ceiling that had black debris/residue on the bottom panel/vent
-Air conditioner unit in the ceiling, located at end of the hall, had filters and vents with dust build up
-Air conditioner unit in the ceiling, across from room 1, had dust build up in the filters/vents
-Air conditioner unit in the ceiling, outside of room 9, had dust build up in the filters/vents
-Room 6 had several broken slats in the horizontal window blinds -Room 6 had no privacy curtain for Bed 2

-The ceiling in the middle of the dayroom, was observed to have ceiling pieces missing, and had ceiling pieces hanging downward over a resident dining table, measuring approximately one foot long and approximately 6 inches in width.

During interview, on 1/4/16 at 3:40 P.M. and 5:05 P.M., the facility Plant Director said that the facility had an outside company who would clean and sanitize all the air conditioning units, but that this had not been done in the last two years. He said that the air conditioning units were on a facility monthly cleaning schedule for filters and vents.

During an interview, on 1/6/17 at 11:30 A.M., the facility Plant Director said that there was a leak in the roof in the Tatnuck unit day room in November, and the ceiling had not been fixed yet. During interview, on 1/6/16 at 1:05 P.M., the facility Administrator and Housekeeping Director said that the shower rooms were wiped down and cleaned daily, but they are not deep cleaned and the grout is not cleaned.

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 staff interview and record review, the facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 (#8) of 24 sampled residents.

Findings include:

For Resident #8, the facility failed to complete a Significant Change MDS when the resident declined in multiple areas of activities of daily living (ADL).

Resident #8 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] indicated the resident had declined in multiple ADLs from supervision/ set up support to extensive assist in the following areas: transfers, ambulation bed mobility and locomotion on and off the unit.

During an interview on 1/6/17 at 11:20 A.M., with the MDS coordinator, she said that the resident had triggered for a Significant Change MDS and it had not been completed.

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 review and interview, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment for 1 resident #8 in a total sample of 24 residents.

Findings include:

For Resident #8, the facility staff failed to correctly code the the use of an antipsychotic medication on an Admission MDS Assessment.

Resident #8 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of section N of the Admission MDS assessment dated [DATE] indicated the resident was receiving an antipsychotic medication. Review of Section S of the of the Admission MDS assessment dated [DATE] indicated the resident was not receiving an antipsychotic medication.

During an interview on 1/6/16 at 11:20 A M. the MDS Coordinator said that section S was inaccurately coded and should have included the resident’s antipsychotic medication use.

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 observations, staff interviews and record reviews, the facility staff failed to develop comprehensive plans of care for 2 sampled residents (#11 and #15), in total of 24 sampled residents.

Findings include:

1. For Resident #11, the facility staff failed to develop a comprehensive care plan related to communication needs and pain status. Resident #11 was admitted to the facility in 12/2010 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/7/16, indicated the resident exhibited unclear speech, was rarely/never understood, was severely cognitively impaired per staff assessment, and received scheduled pain medications.

Review of the Care Area Assessment (CAA), dated 7/8/16, indicated that the care areas for communication and pain were addressed in the resident’s care plan. Review of the Care Plan Problems List/Triggers, form undated, did not indicate that communication and pain were identified triggers for care planning. Review of the Interdisciplinary Team Meeting forms, dated 7/27/16 and 10/25/16, indicated that the resident speaks a language other than English, and had scheduled medications for pain management. Review of the resident care card, revised 10/26/16, indicated the resident had a primary language other than English. The surveyor observed Resident #11, on 1/3/17 at 2:40 P.M., sitting at a table, with other residents, in the dayroom with his/her eyes closed, while music was playing. During an interview, on 1/6/17 at 11:15 A.M., the PPS Coordinator said that Resident #11 did not have current care plans for pain and communication and that there should have been care plans in place.

2. For Resident #15, the facility staff failed to develop a comprehensive care plan relative to [MEDICAL CONDITION] medications.

Resident #15 was admitted to the facility in 11/2016, with [DIAGNOSES REDACTED]. Review of the Admission MDS, with an ARD of 12/2/16, indicated that the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, experienced feeling down, depressed or hopeless, and received 6 days of antianxiety and antidepressant medication during the assessment period.

Review of the CAA, dated 12/7/16, indicated that the care area for [MEDICAL CONDITION] drug use would be addressed in the resident care plan. Review of the 1/2017 physician’s orders [REDACTED]. twice daily as needed. The surveyor observed Resident #15 on 1/6/17 at 1:50 P.M., lying in bed with oxygen, via nasal cannula, on him/her. During an interview, on 1/6/17 at 3:30 P.M., Unit Manager #3 said that the care plan for [MEDICAL CONDITION] medications was missed.

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 observation, record review and interview, the facility staff failed to follow facility policy and/or physician orders for 4 sampled residents ( #1, #13 #18 and #20), in a total sample of 24 residents.

Findings include:

1. For Resident #1, the facility staff failed to document on the physician interim orders. Resident#1 was admitted to the facility in 10/2009, with [DIAGNOSES REDACTED]. Review of the facility Physician’s Orders-Transcription Policy, dated (MONTH) (YEAR), indicated telephone physician’s orders must be duly noted and accurately transcribed by licensed nursing staff.

Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/6/16, indicated in section N that the Resident received anticoagulant medications for 7 days. Review of the medical record, indicated the Resident had a INR (International Normalized Ratio- blood test to evaluate coagulation) drawn on 12/14/16.

Review of the laboratory report sheet, dated 12/14/16, indicated a physician telephone order written indicating that the Resident was receiving 5.5. mg(milligrams) of [MEDICATION NAME] (anticoagulant-blood thinning agent) every other day with 5 mg on the alternate days.

Review of the INR lab result, drawn on 12/28/16, the Laboratory Report sheet indicated a physician telephone order that the INR was to be repeated in one week. During an interview, on 1/4/17 at 4:00 P.M., Unit Manager (UM) #2 said the order for [MEDICATION NAME] 5.5 mg every other day with [MEDICATION NAME] 5 mg on opposite days and the order for repeat INR in one week should have been written on a Physician Order Sheets and not on a laboratory report sheet.

2. For Resident #13, the facility staff failed to obtain a physician order for [REDACTED].>Resident #13 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], indicated in section J1100, the resident had shortness of breath with exertion and at rest. Review of section O0100 in the Admission MDS, indicated oxygen therapy was used by the resident at the facility. During an observation, on 1/3/17 at 4:00 P.M., the resident was sitting in a wheelchair at his/her bedside, and had oxygen on at 3 lpm (liters per minute) via nasal cannula.

During an observation, on 1/4/17 at 8:00 A.M., the resident was awake in bed and had oxygen on at 3 lpm via nasal cannula. During an observation, on 1/5/17 at 9:10 A.M., the resident was sitting up in bed, eating breakfast, and had oxygen on at 3lpm via nasal cannula. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Record (TAR), indicated to administer oxygen at 3 lpm via nasal cannula continuously for [DIAGNOSES REDACTED]. Review of the medical record, indicated there was no physician order written [REDACTED]. During an interview, on 1/5/17 at 4:00 P.M., UM #4 said there were no written physician orders for the use of oxygen for (MONTH) (YEAR) and (MONTH) (YEAR).

3. For Resident #18, the facility staff failed to transcribe oxygen orders, and to document oxygen saturation on the (MONTH) (YEAR) TAR. Resident #18 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], indicated in section J0100, the resident had shortness of breath with exertion.

Review of section O0100 in the Admission MDS, indicated oxygen therapy was used by the resident at the facility. During an observation, on 1/5/17 at 8:45 A.M., the resident was lying in bed with his/her eyes closed and had oxygen on at 2 lpm via nasal cannula.

During a review of the medical record, indicated a physician order to administer oxygen at 2-4 lpm prn (as needed), to maintain oxygen saturation levels above 90 %. Review of the (MONTH) TAR, indicated there was no order to administer oxygen or to check the resident’s oxygen saturation level. During an interview, on 1/5/17 at 9:00 A.M., UM #4 said there was no order on (MONTH) (YEAR) TAR to administer oxygen or to check the resident’s oxygen saturation level.

4. For Resident #20 the facility staff failed to ensure they had Physician orders for sliding scale insulin. Resident #20 was admitted to the facility 9/2008, with [DIAGNOSES REDACTED].

Review of the current signed 12/2016 physician orders indicated the resident was to have a finger stick blood sugar(FSBS) twice daily and an order dated as initiated 6/16/16 for the resident to receive Humalog insulin (rapid acting insulin) inject dose according to sliding scale. There were no Physician orders for a sliding scale insulin dose.

Review of the 11/2016, 12/2016 and 1/2017 Glucose Monitoring /Insulin Administration form included the following information:

-name, room and Physician name
-type of insulin & dose
-sliding scale order

The form indicated that the Resident #20 had been provided Humalog insulin twice a day in accordance with a sliding scale that was listed on the form as follows:

-if blood sugar(BS) less than 60 notify physician
-BS 151-200 give 2 units
-BS 201-250 give 4 units
-BS 251-300 give 6 units
-BS 301-350 give 8 units
-BS 351-400 give 10 units call MD
-if BS greater than 400 notify MD

During interview with Unit Manager #3 on 1/6/16 at 2:00 P.M. she said the sliding scale insulin Physician orders were lost in the editing process and she would need to obtain a Physician clarification order.

Failed to make sure that each resident's drug regimen is free from unnecessary drugs; each resident's entire drug/medication is managed and monitored to achieve highest well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff inteviews and record reviews, the facility staff failed to ensure that [MEDICATION NAME] (an anticoagulant medication), was administered as ordered for 1 sampled resident (#12) in a total of 24 sampled residents.

Findings include:

Resident #12 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Laboratory Report, dated 12/30/16, indicated a notation for 6 milligrams (mg.) (no medication indicated on the form) on Monday, Wednesday, Friday, Saturday, and Sunday. Review of the clinical record, indicated that there was no Physician’s Telephone Order completed on 12/30/16.

Review of the current Medication Administration Record [REDACTED]. The surveyor observed Resident #12 on 1/4/17 at 11:05 A.M., seated in a wheelchair, positioned in the hallway.

The resident was wearing glasses, a johnny and had bilateral protective boots in place.

During an interview, on 1/4/17 at 3:40 P.M., Nurse #2 said that Resident #12 receives [MEDICATION NAME] 6 mg daily at 5:00 P.M.

During an interview, on 1/4/17 at 3:45 P.M., Unit Manager (UM) #2 said that Resident #12 should not have received [MEDICATION NAME] 6 mg on Tuesday, and that the Assistant Director of Nurses (ADON) would be notified of the medication error.

Failed to develop policies and procedures for influenza and pneumococcal immunizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure that 3 residents (#8, #17 and #18) were offered the pneumococcal or flu vaccine, or indicate in the clinical record the resident had received the vaccine previously, had a medical contraindication or refused, in a total sample of 24 residents.

Findings include:

1. For Resident #8 the facility staff failed to administer the pneumococcal vaccine when consent for the administration had been obtained. Resident #8 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Record review indicated a Consent for Immunization form was signed by the guardian on 10/14/16, consenting to the administration of the pneumococcal vaccine.

Review of the clinical record indicated the pneumococcal vaccine section of the Immunization Record was blank. During interview on 1/6/17 at 4:55 P.M. with the Assistant Director of Nursing(ADON) she said that the resident had consent to receive the pneumococcal vaccine and that it had not been administered.

2. For Resident #17 facility staff failed to ensure the resident was offered to receive or decline the administration of the flu and pneumococcal vaccines. Resident #17 was admitted ,[DATE] with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].

Review of the clinical record indicated the following blank (with the exception of the resident’s name) forms: Immunization Record, Consents for Immunizations, Resident Influenza Vaccine Consent and Education Documentation Form and a Resident Pneumonia Consent and Education Documentation Form.

During interview on 1/6/16 at 5:05 P.M., Unit Manager(UM) #3 said that the immunizations were on the Physician admission orders [REDACTED].

3. For Resident #18, the facility staff failed to offer the Resident an Influenza vaccination upon admission to the facility.

Resident #18 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment (MDS), with an Assessment Reference Date (ARD) of 12/23/16, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Review of the Immunization of Residents Policy, (dated 4/2016), indicated all eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. Review of the Physician Orders, dated 12/16/16, indicated an order to administer the flu vaccine. Review of the MDS, dated [DATE], section O, indicated the influenza vaccine was not assessed.

Review of the Resident’s Immunization Record, indicated no influenza vaccine was given. Review of the Resident Admission Vaccination Education Form, indicated no education was provided to the Resident. During an interview, on 1/5/17 at 8:50 A.M., UM #4 said the Resident was not offered the influenza vaccine.

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

Based on observations and interviews, the facility staff failed to ensure that the facility census and nurse staffing information were posted in a location that is prominent, and readily accessible to residents and visitors, on a daily basis.

Findings include:

During an observation, on 1/3/17 at 7:00 A.M., the surveyor observed that there was no resident census and nurse staffing information posted upon entrance to the facility, within the lobby or entrance hallways.

During an observation, on 1/4/17 at 5:45 P.M., the surveyor observed a white board that had staffing and census lines that should have been filled out, but was blank, located in the facility lobby between the entrance doors.

During an observation, on 1/5/17 at 11:40 A.M., the surveyor observed the white board, located in the facility lobby between the entrance doors, that did not contain the information for resident census and nursing staffing. the required posting was not found anywhere else in the facility.

During an interview, on 1/5/17 at 11:40 A.M., the Administrator said that the white board located in the facility lobby between the entrance doors, has not been completed since she has been employed at the facility.

Failed to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Based on observations, test trays, Group Meeting and interviews, the facility failed to ensure that food was served at the proper temperatures for 1 sampled residents ( #12) in a total sample of 24 residents and for 5 non-sampled residents (NS #1, NS #2, NS #3, NS #4 and NS #5).

Findings include:

a. During the group meeting held on 1/4/17 at 10:00 A.M. 5 of 5 non-sampled residents (NS #1, NS #2, NS #3, NS #4 and NS #5) attending the group meeting said that cold food temperatures, usually the breakfast meal, continues to be a problem. The residents further stated that after the food truck arrives on the unit, the food truck frequently sits for several minutes, prior to the food being served.

b. The Surveyor conducted a test tray on 1/5/15 on the Vernon/Greendale Unit. The following were observed: – Review of the Truck Delivery Sheet, indicated that the first food truck was scheduled to arrive on the unit at 8:25 A.M., followed by the second food truck at 8:40 A.M.

– At 9:02 A.M. the first food truck arrived on the unit.
– At 9:05 A.M. a staff member checked the food trays, closed the food truck door, and left the area.
– At 9:12 A.M., the second food truck, containing the test tray, arrived on the unit, and the first tray was passed. Staff continued to pass the trays from both of the food trucks.
– At 9:31 A.M. the last tray was passed and at 9:32 A.M. the surveyor conducted a test tray.

The following temperatures were out of compliance:
– Pancakes, 99.5 degrees Fahrenheit (F), cold to taste.
– Sausage Patty, 103.2 degrees F., cool to taste.
– Milk, 47.3 degrees F., cool to taste.

The temperatures were verified with Unit Manager #3, who observed the test tray.

c. The surveyor conducted a test tray on 1/5/17 on the Burncoat Unit. The following were observed:

-Review of the Truck Delivery Sheet, indicated that the meal truck was scheduled to arrive on the unit at 7:45 A.M.
-At 8:15 A.M., the meal truck arrived on the unit.
-At 8:55 A.M., the surveyor conducted a test tray.

The following temperatures were out of compliance:
-Pureed pancakes, 116.1 degrees F, room temperature to taste.
-Pureed eggs, 114.1 degrees F, room temperature to taste
. – Pureed sausage, 97.6 degrees F, room temperature to taste.
-Milk, 55.5 degrees F, slightly cool to taste.

d. The surveyor conducted a test tray on 1/5/17 on the Tatnuk Unit. The following were observed:

-Review of the Truck Delivery Sheet, indicated that the meal truck was scheduled to arrive on the unit at 8:05 A.M.
-At 8:12 A.M., tray service began for the Tatnuk unit.
– At 8:30 A.M., the meal truck left the kitchen.
-At 8:38 A.M., the meal truck arrived on the unit.
-At 8:50 A.M., the surveyor conducted a test tray.

The following temperatures were out of compliance:
-Pancakes, 106 degrees F, room temperature to taste.
-Sausage patty, 102.6 degrees F, room temperature to taste.

The temperatures were verified with Unit Manager # 2, who observed the test tray. e. Review of the Meal Distribution Policy, (dated 5/2014), indicated the following: meals are transported to the dining locations in a manner that ensures proper temperature maintenance, and are delivered in a timely and accurate manner. During an interview, on 1/6/17 at 4:15 P.M., the Administrator said that she and the Food Service Director are aware of the meal temperature complaints and are working on it.

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 medications and biologicals were of current date to provide reliability of strength and accuracy of dosage on 4 of 4 units.

Findings include:

1. During an inspection of the Transitional Care Unit medication room, on 1/3/17 at 2:15 P.M., a bottle of Ativan liquid (medication used for anxiety) was found in the medication refrigerator with an expiration date of 10/16. During an interview, on 1/3/17 at 2:20 P.M., Unit Manager (UM) #4 said the Ativan was expired.

2. During an inspection of the Vernon/Greendale Unit medication room, on 1/3/17 at 3:30 P.M., the following expired medications were found in the medication refrigerator:

– One box of 12 Ativan suppositories with an expiration date of 12/18/15.
-One open vial of Afluria Influenza Vaccine (used for active immunization against influenza) with no documentation of date opened (vial must be discarded within 28 days of opening).
-One open vial of Afluria Influenza Vaccine with a documented open date of 10/4/16. During an interview, on 1/3/17 at 3:35 P.M., UM #3 said the Ativan suppositories, and both vials of Afluria Influenza Vaccines were expired.

3. During an inspection of the Burncoat Unit medication room, on 1/3/17 at 4:00 P.M., the following expired medications were found:
-One open vial of Afluria Influenza Vaccine with a documented open date of 11/13/15.
-One open vial of Mantoux Vaccine (a screening test for [DIAGNOSES REDACTED], an infection of the lungs) with no open date documented (vial must be discarded within 30 days of opening).

During an interview, on 1/3/17 at 4:05 P.M., Nurse #1 said the vial of Afluria Influenza Vaccine and Mantoux Vaccine were expired.

4. During an inspection of the Glendale Unit treatment cart, on 1/5/17 at 2:00 P.M., the following expired items were found:
-One box of Algisite M ( dressing used for moist wound management), with an expiration date of 7/16.
-One box of Biatin Super Adhesive ( highly absorbent wound dressing), with an expiration date of 7/16.
-One box of Polymem Non-Adhesive (dressings used for wounds), with an expiration date of 8/16.

During an interview, on 1/5/17 at 2:10 P.M., UM #3 said the Algisite M, Biatin Super Adhesive and Polymem Non-Adhesive dressings were expired and discarded them.

Failed to keep all essential equipment working safely.

Based on observations and interviews, the facility staff failed to provide accommodations to afford personal privacy for 1 sampled resident (#12), in a total of 24 sampled residents.

Findings include:

Resident #12 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. During an observation, on 1/3/17 at 9:00 A.M., the surveyor observed Resident #12’s room. The surveyor observed a window adjacent to the resident’s bed that was missing 4 slats to the vertical blinds that were in place to cover the window. The surveyor observed that the parking lot was clearly visible through the vertical blinds which were closed because of the missing slats.

During an interview, on 1/4/17 at 1:00 P.M., Resident #12 said that the privacy curtain does not reach the window to provide privacy from the parking lot.

During an observation, on 1/4/17 at 2:30-3:00 P.M., the surveyor observed Resident #12, seated in a wheelchair, positioned in front of the window with the 4 missing vertical slats. The surveyor observed two people outside of the window in the parking lot.

During an interview, on 1/6/17 at 11:30 A.M., the Director of Environmental Services said that the vertical blinds nor the privacy curtain did not provide privacy from the parking lot located outside of the window.

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, observation and staff interview, the facility failed to ensure the resident’s clinical record was complete and accurately documented, for 2 residents (#4 and 13), out of a total sample of 24 residents.

Findings include:

1. For Resident #4 the facility failed to ensure that a physician’s order for Oxygen was complete.

Resident #4 was admitted to the Facility in 7/1999 with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 9/15/16, indicated that the resident had a [DIAGNOSES REDACTED].

Review of the 11/2016 Physician Order Sheet indicated the following Physicians Order: Oxygen at (space) Liters Per Minute (LPM) via (space) continuously for the [DIAGNOSES REDACTED].

Review of the Physician’s Telephone Order, dated 11/2/17, indicated the following clarification: Discontinue Oxygen at 2 LPM, via nasal cannula continuously to maintain Oxygen Saturation Levels over 90 percent. Review of the 11/2016, Treatment Administration Record (TAR), indicated that on 11/1/16 and 11/2/16 the resident utilized Oxygen at 2 LPM, via nasal cannula continuously to maintain Oxygen Saturation Levels over 90 percent.

Further review of the TAR indicated that the order was discontinued on 11/2/16. Review of the 12/2016 Physician Order Sheet indicated the following Physicians Order: Oxygen at (space) Liters Per Minute (LPM) via (space) continuously for the [DIAGNOSES REDACTED].

Review of the 12/2016 TAR, indicated that the resident utilized Oxygen at 2 LPM, via nasal cannula continuously, daily, although the physician ‘ s order did not specify the flow rate of the method of administration of the Oxygen. Review of the Annual MDS Assessment, dated 12/15/16, indicated that the resident had a [DIAGNOSES REDACTED]. Review of the 1/2017 Physicians Order Sheets indicated no order for Oxygen. Review of the 1/2017 TAR, indicated that the resident utilized Oxygen at 3 LPM, via nasal cannula continuously, from 1/1/17-1/5/17 although there was no physician’s order for the use of [REDACTED]

The surveyor observed Resident #4 on 1/5/17 at 1:30 P.M. Resident #4 was seated in his/her room facing the doorway. The resident was receiving oxygen via nasal cannula in his/her nose. During an interview with Unit Manager #3 on 1/5/17 at 1:45 P.M., she said that the Pharmacy did not carry forward the orders for Oxygen onto the Physician’s Order Sheets and the Oxygen order was incomplete.

2. For Resident #13, the facility staff failed to accurately document the resident’s continence status on the continence care plan. Resident # 13 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 12/14/16, indicated the resident was always continent for urinary and bowel continence. Review of the Admission /Re-Admission Nursing Evaluation, dated 12/7/16, indicated the resident was continent for bladder and bowel. Review of the Bladder and Bowel Evaluation, dated 12/7/16, indicated the Resident was continent of bladder and bowel. Review of the Certified Nurse Aide (CNA) Flow Sheets, dated (MONTH) (YEAR), indicated the resident was continent of bladder except for 2 shifts that month.

Review of the CNA Flow Sheets, dated (MONTH) (YEAR), indicated the resident was continent of bladder and bowel. Review of the Resident Care Card, dated 12/8/16, indicated the resident was continent of bowel and incontinent of bladder.

Review of the Incontinence Care Plan, dated 12/7/16, indicated the resident was incontinent of bladder and incontinent of bowel. During an interview, on 1/3/17 at 12:05 P.M., Certified Nurse Aide (CNA) #2 said the resident was continent of bladder. During an interview, on 1/5/17 at 9:10 A.M., the resident said he/she was continent of bowel and bladder. During an interview, on 1/5/17 at 4:05 P.M., CNA #3 said the resident was continent of bladder.

Parsons Hill Rehabilitation & Health Care Center, 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).

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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 – Parsons Hill Rehabilitation & Health Care Center

Inspection Report for Parsons Hill Rehabilitation & Health Care Center – 01/06/2017

Page Last Updated: August 2, 2018

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