Wingate at Sudbury

Wingate at Sudbury

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About Wingate at Sudbury

Wingate at Sudbury is a for profit, 142-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Maynard, Acton, Concord, Hudson, Wayland, Marlborough, Westford, Weston, Bedford, Southborough, Chelmsford, Clinton, Framingham, Lexington, and the other towns in and surrounding Middlesex County, Massachusetts.

Wingate at Sudbury
136 Boston Post Rd,
Sudbury, MA 01776

Phone: (978) 443-2722
Website: https://wingatehealthcare.com/location/wingate-at-sudbury/

CMS Star Quality Rating

Wingate at SudburyThe 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, Wingate at Sudbury in Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against Wingate at Sudbury

The Federal Government fined Wingate at Sudbury $2,925 on 06/24/2016 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Wingate at Sudbury committed the following offenses:

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, policy reviews, and record review, the facility staff failed to notify the Physician of an unplanned overnight leave of absence (LOA) for 1 sampled resident (#8) which resulted in multiple scheduled medications not being administered as ordered by the Physician.

Findings include:

Resident #8 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the facility policy Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Notification Guidelines, revised 2/2011, indicated the following:

– it is the responsibility of the licensed professional nurse to observe for changes in resident condition, to make assessments of the change, and to notify the Physician/NP/PA. Review of the facility policy Medication Administration-General Guidelines, dated 1/2016, indicated the following:

– if a regularly scheduled medication is withheld, refused, not available or given at a time other then the scheduled time (e.g. the resident is not in the facility at the scheduled dose time .), an explanatory note is entered on the reverse side of the record. If consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. Review of the Annual Minimum Data Set (MDS) Assessment, dated 12/21/16, indicated Resident #8 had delusions and episodes of rejecting care that had worsened since the previous assessment, had moderate pain and received scheduled pain medication, and received an antidepressant medication.

Review of the Physician Order Report, dated 2/2017, indicated Resident #8 did not have an order for [REDACTED].>- [MEDICATION NAME] (pain reliever/fever reducer) 325 milligrams (mg.) 2 tablets (650 mg) three times daily at 6:00 A.M., 2:00 P.M., and 10:00 P.M.

– Aspirin (pain reliever/fever reducer) 81 mg, 1 tablet daily at 9:00 A.M.
– [MEDICATION NAME] XL (medication for overactive bladder) 10 mg, 1 tablet daily at 9:00 A.M.
– [MEDICATION NAME] (medication to treat high blood pressure and heart failure) 10 mg, 1 tablet daily at 9:00 A.M.
– [MEDICATION NAME] (blood thinner to prevent stroke, [MEDICAL CONDITION]) 75 mg, 1 tablet daily at 9:00 A.M.
– [MEDICATION NAME] (antidepressant) 25 mg, 2 tablets daily at 9:00 A.M.
– [MEDICATION NAME] (stool softener) 100 mg, 1 capsule twice daily at 9:00 A.M. and 9:00 P.M.
– [MEDICATION NAME] Powder (laxative), 17 grams/dose twice daily at 9:00 A.M. and 5:00 P.M.
– [MEDICATION NAME] (blood pressure medication) 50 mg, half tablet every 12 hours at 9:00 A.M. and 9:00 P.M.
– [MEDICATION NAME] (antidepressant) 50 mg, half tablet daily at 4:00 P.M. – [MEDICATION NAME] 50 mg, 1 tablet daily at 8:00 P.M.
– Senna (laxative) 8.6 mg, 2 tablets daily at 5:00 P.M.
– [MEDICATION NAME] (medication to treat nerve pain) 300 mg, 1 capsule daily at 9:00 P.M.
– Atorvastatin (used to treat high cholesterol) 10 mg, 1 tablet daily at 9:00 P.M.
– [MEDICATION NAME] (sleep aid) 3 mg, 3 tablets daily at 9:00 P.M.
– [MEDICATION NAME] (narcotic used to treat moderate to severe pain) 50 mg, two half tablets at 9:00 P.M.

Review of the nurse’s note, dated 2/11/17 at 1:30 P.M., indicated Resident #8 had an eye injection appointment and that his/her son would transport to the appointment. The nurse’s note indicated that all afternoon medications were given at 1:00 P.M., and that the resident and his/her son left at 1:30 P.M.

Review of the Medication Administration Record [REDACTED] – [MEDICATION NAME] at 10:00 P.M.
– [MEDICATION NAME] at 9:00 P.M.
– [MEDICATION NAME] at 5:00 P.M.
– [MEDICATION NAME] at 9:00 P.M.
– [MEDICATION NAME] at 4:00 P.M. and 8:00 P.M.
– Senna at 5:00 P.M.
– [MEDICATION NAME] at 9:00 P.M.
– Atorvastatin at 9:00 P.M.
– [MEDICATION NAME] at 9:00 P.M.
– [MEDICATION NAME] at 9:00 P.M.

Review of the 2/2017 MAR Medication Notes, indicated an entry on 2/11/17 at 12:30 P.M. indicating [MEDICATION NAME] (anti-anxiety medication) was administered prior to appointment for the eye injection. There was no documentation that indicated why scheduled medications for the 3:00 P.M. to 11:00 P.M. shift were not administered as ordered on [DATE].

Review of the nurse’s note, dated 2/12/17 at 8:00 A.M., indicated that the resident did not return from his/her eye appointment. The resident’s health care proxy (HCP) was updated. There was no indication that the Physician was notified of the resident’s unplanned overnight LOA or updated about the scheduled medications that were not administered.

Review of the nurse’s note, dated 2/12/17 at 1:30 P.M., indicated the resident was returned to the facility by his/her HCP and given all A.M. medications missed while on LOA. Vital signs were obtained. Review of the 2/2017 MAR Medication Notes, indicated an entry on 2/12/17 at 1:30 P.M. that all medication for A.M. were given at 1:30 P.M. and that [MEDICATION NAME] was administered.

Review of the clinical record did not indicate if the Physician had been notified that the scheduled morning medications were given late on 2/12/17.

During an interview on 7/21/17 at 9:25 A.M., Unit Manager (UM) #1 said she was unable to find a Physician’s order indicating the resident could have an LOA. She further said, after reviewing the clinical record with the surveyor present, that there was no indication the Physician was notified about the resident’s unplanned LOA or that he/she had missed multiple scheduled medications.

During an interview on 7/21/17 at 10:20 A.M., Nurse #4 (who was present on the day the resident returned to the facility on [DATE]) said she did not notify the Physician about the A.M. medications that were given late. She further said the resident’s blood pressure was elevated and he/she was tearful when he/she returned to the facility from the overnight. Nurse #4 said she administered the scheduled 9:00 A.M. medications at 1:00 P.M., but did not call the Physician.

Failed to provide housekeeping and maintenance services.

Based on observations during a tour of the environment and interviews, facility staff failed to provide maintenance and housekeeping services necessary for residents’ environment for a sanitary, orderly, and comfortable/homelike interior for residents on 2 of 4 nursing units, in common areas and resident rooms.

Findings include:

During tours of the environment and interview with the Director of Maintenance on 7/19/17 6:50 A.M., 7:10 A.M., 12:00 P.M., 12:43 P.M., and with Director of Maintenance (7/19/17 from 3:20 P.M. – 3:38 P.M.) the following were observed: First floor (two units/sides) Bathing Suite (shared by residents both sides) Observed (on 7/19/17 from 12:15 P.M. – 12:45 P.M.) two Janitor’s carts with water in pails. One of the carts had a mop soaking in gray-colored water. There were various supplies on the carts, but none appeared to be chemicals, unsanitary to store Janitor’s carts in an area where residents bathed/showered. The walls inside the long room were heavily scuff, with gouges on the wall surfaces. There was a sign posted inside the door indicating that the floor was slippery when wet (should not be slippery when staff and residents alike are using shower where floors are likely to be wet.) The floor was stained and worn.

On 7/19/17 at 1:30 P.M., Housekeeper (Hsk) #1 said that she puts her Janitor’s cart in the Residents’ bathing/shower suite when she takes a break for lunch and periodically. Hsk #1 said that the other Janitor’s cart was stored in the Bathing/Shower suite, and belonged to Hsk #2. The Housekeeping supervisor was present and interpreted due to a language barrier. She instructed both Hsk #1 and #2 to place the carts in the Janitor’s closet, not the Residents’ shower/bathing areas as this was not sanitary. Resident’s Rooms/bathrooms were unsanitary, needed repair, to ensure homelike as follows:

– Room 105: scuffed wall surfaces.
– Room 109: Toilet paper holder was broken. The broken piece was stored on the sink.
– Room 110: Bathroom had a pink wash basin which stored a bedpan/ there was a drinking mug on the sink and a toothbrush in an emesis basin also stored on the sink, room shared by two residents.
– Room 112: Spackled walls need painting, not homelike.

– Room 113: Privacy curtain stained brown in several areas bed A. Window dirty/filmy coating. Bathroom: light was not working. Increased clutter, 3 drawer storage bin with 2 wheelchair leg rests on top. Another large bin propped against the wall behind this. A metal basket attached to the wall held a wash basin, a broken piece to a toilet paper holder, toiletries, and loose gloves. There was a square opening in the wall under the toilet area with exposed pipes. The floor surface was very slippery and was not wet.

– Room 123: Windows filmy and dirty. Bathroom: Wallpaper torn and discolored/stained. Towel bar stored personal hygiene products not labeled as to whom they belonged
. – Room 124: Call light for Bed A had scotch tape holding it in place. There was a nebulizer mask with attached tubing dated as being changed 5/23/17 (should have been changed weekly in accordance to Nurse #3).
– Room 125: Bed B. Strong offensive foul urine odor emanated from the bed area. The windows were filmy/dirty. Wall plate with protruding cable wire was loose and the loose wall plate revealed a hole behind this. The walls were scuffed.
– Room 127: Large section of ceiling tiles. located above the toilet in the bathroom were stained with a dark brown-black substance. During interview on 7/19/17 at 3:20 P.M., the Maintenance Director said that there are many issues that he tries to address daily. He said that he is the only Maintenance person working at the facility and receives piles of work order requests from staff, that he works diligently to repair. He said that in addition to this, he receives multiple phone calls and messages for immediate repairs and concerns and is working very hard to ensure all maintenance issues are addressed. The Maintenance Director said that the issues with stained tiles in bathroom were most likely condensation, and he will ensure everything is repaired and fixed accordingly.

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, observation and interviews, facility nursing staff failed to provide services in accordance with nursing standards of practice for 2 (#6 and #12) sampled residents, and 2 Non-sampled Resident (NS #1, NS #2) from a total of 22 sampled residents and 2 NS resident related to [MEDICATION NAME] (injectable blood thinning medication) and Insulin (injectable medication used to treat Diabetes Mellitus) administration.

Findings include:

During interview with the Director of Nursing (on 7/19/17 at 9:20 A.M.), the Director said the Facility did not have a policy regarding rotation of injection sites for those medications requiring injection rotation and documentation.

According to the Nursing (YEAR) Drug Handbook, pages 526-529, [MEDICATION NAME], with patient lying down, give by deep subcutaneous injection, alternating doses between the left and right anterolateral and posterolateral abdominal walls. Rotate sites and keep record.

1. For NS Resident #1, nursing staff failed to ensure [MEDICATION NAME] (injectable blood thinning medication) injection sites had been documented, and identified as being rotated, as required. During part of the medication pass on 7/19/17 at 7:31 A.M. with Nurse #1, he said that he would administer [MEDICATION NAME] after the Resident was done breakfast as the Resident was already seated in the Dining Room.

On 7/19/17 at 9:08 A.M., Nurse #1 administered [MEDICATION NAME] injection in the Resident’s left lower quadrant of the abdomen appropriately. However, he did not record the location where it was administered. Further review of the corresponding MAR indicated Licensed Nursing initials after the injection had been administered for 9:00 A.M. There was nothing recorded as to the location or indication that the [MEDICATION NAME] injection had been rotated in the abdomen, in accordance with nursing standards of practice and instructions from the Nursing (YEAR) Drug Handbook. During interview on 9:16 A.M., Nurse #1 said that he did not document an injection site, and that there should be a place to record this on the MAR. Nurse #1 said that there was no way to ensure the [MEDICATION NAME] injections had been rotated.

2. For NS #2, nursing staff failed to ensure the clinical record was accurately recorded related to [MEDICATION NAME] injections (injectable blood thinning medication). NS #2 was admitted to the Facility in 4/2016 with [DIAGNOSES REDACTED]. During the medication pass with Nurse #2 on 7/19/17 at 8:58 A.M., the Surveyor observed Nurse #2 administer a [MEDICATION NAME] injection into the Resident’s left lower/middle aspect of the abdomen appropriately.

Nurse #2 then documented a check mark on the Medication Administration Record (MAR) indicating that he administered the injection in the Right(R)/(L) Left arm, which he did not.

During interview, directly after what had been observed and documented on the MAR on 7/19/17 at 9:02 A.M., the Surveyor asked Nurse #2 where he just administered the [MEDICATION NAME], to which Nurse responded the left abdomen. The Surveyor then asked Nurse #2 why he documented he administered the [MEDICATION NAME] into the arm, inaccurately. The Surveyor then observed that there were several entries by other Licensed Nurses indicating the [MEDICATION NAME] had been administered in the R/L arm. Nurse #2 said, that is not correct. He said [MEDICATION NAME] must be administered in the abdomen and rotated for proper absorption. Nurse #2 said that the other nurses must have mistakenly documented the injection site as being the arm, just as he did. Further review of the MAR indicated that NS #2 received [MEDICATION NAME] in the R/L arm on 7/3, 7/9, 7/11, 7/13, 7/15 and for this morning’s dose on 7/19/17 at 9:00 A.M. After pointing this out to Nurse #2, Nurse #2 circled the check mark he documented inaccurately for the arm, then proceeded to cross out the entry indicating the injection site for the arm, thus altering the clinical record where several other Licensed Nurses had documented. Nurse #2 said that he should not have crossed out the entry, and would reprint the correct information in the computer to ensure the R/L arms were not an option for injection sites, and would alert the Supervisor he altered the record in haste.

3. For Resident #6, the facility staff failed to ensure the rotation of insulin injection sites.

Review of the Nursing (YEAR) Drug Handbook indicated the following relative to long acting insulin administration:

Administer by subcutaneous (sc) injection only in the thigh, abdominal wall or upper arm. Rotate sites within the same region from one injection to the next to reduce the risk of [DIAGNOSES REDACTED] (hardening of the tissue resulting in decreased absorption). Resident #6 was admitted to the facility in 8/2016 with a [DIAGNOSES REDACTED]. Review of the 7/2017 MAR indicated a physician’s orders [REDACTED].

In addition, the MAR indicated the resident was to receive [MEDICATION NAME] Insulin Pen (a long acting insulin), 70 units sc at bedtime. The only documentation to indicate the injection site was a checkmark. On 7/25/17 at 10:45 A.M. during an interview with the DON, she said she was working on a better way to document injections sites. The current way wasn’t clear.

4. For Resident #12, the facility staff failed to ensure the rotation of Insulin and [MEDICATION NAME] injection sites. Resident #12 was admitted to the facility in 7/2017 with a [DIAGNOSES REDACTED]. Review of the 7/2017 MAR indicated an order for [REDACTED].M. The only indication for documentation of the injection site was, on most days, a checkmark. In addition, the MAR indicated an order for [REDACTED]. sc once a day. The only indication for documentation of the injection site was a check mark. Further review indicated an order for [REDACTED].M. The majority of documentation to indicate the injection site was a checkmark. On 7/25/17 at 10:45 A.M. during an interview with the DON, she said she was working on a better way to document injections sites. The current way wasn’t clear.

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 observations, interviews and record reviews, the facility staff failed adhere to the resident plan of care or Physician’s orders for 5 sampled residents (#7, #8, #9, #12 and #13), in a total of 22 sampled residents.

Findings include:

1. For Resident #8, the facility staff failed to ensure that fall interventions were implemented as per the plan of care relative to the resident’s personal bag being on his/her person and implementation of a chair alarm. Resident #8 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the resident falls care plan, initiated 7/13/15, indicated the resident was at risk for falls related to decreased muscle strength, poor safety awareness and antidepressant medications. Interventions included: keep personal items and frequently used items within reach, give verbal reminders not to ambulate/transfer without assistance.

Review of the Physician Order Report, dated 2/2017, indicated an order to apply bed and chair alarms at all times (initiated 3/11/16), and for staff to check placement and functioning every shift. Review of the resident falls care plan, revised 3/26/17, indicated for staff to ensure the resident had his/her bag with him/her at all times, and to encourage the use of a reacher. Review of the facility Event/Incident Report, dated 4/25/17, indicated the resident experienced an unwitnessed fall in his/her room at 5:00 A.M. The investigation indicated that the resident was attempting to reach his/her bag, which was not accessible as per plan of care, and was found lying on the floor. The intervention added to the plan of care after the fall included to re-educate staff regarding having essential items within the residents reach.

Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 6/7/17, indicated the resident had severe cognitive impairment, required extensive assistance of 1 staff for transfers, dressing, toileting and personal hygiene, was non-ambulatory and utilized a wheelchair, and experienced 2 falls with no injury since the last assessment. Review of the Treatment Administration Record (TAR), dated 7/2017, indicated application of a bed and chair alarm at all times and for staff to check placement and function every shift. Review of the facility Event/Incident Report, dated 7/13/17, indicated the resident experienced an unwitnessed fall in his/her room at 11:15 A.M. The investigation indicated that the resident slid out of his/her wheelchair while reaching for an item on the floor. Further review of the investigation indicated that the chair alarm was not on as ordered. During an observation on 7/21/17 at 8:00 A.M., the resident was seated in wheelchair in the dayroom with other residents. No staff were present. The resident was observed to be dressed and wearing shoes, did not have an alarm box on his/her chair, nor was his/her personal bag with him/her, as care planned.

During an interview on 7/21/17 at 9:15 A.M., Certified Nurse Aide (CNA) #1 said Resident #8 uses a bed and chair alarm. When the surveyor asked CNA #1 if the resident had on his/her chair alarm, CNA #1 said that sensor pad was on the resident’s wheel chair, but the alarm box was not, therefore, the alarm would not sound if the resident attempted to stand up. During an interview on 7/21/17 at 9:25 A.M., Unit Manager (UM) #1 said the CNAs check resident alarms on rounds. Nurses document in the treatment record that the alarms are in place. She said the resident has had falls because he/she tends to reach for his/her personal bag. The surveyor asked UM #1 if the resident currently had his/her personal bag with him/her as care planned, and UM#1 said he/she did not have it but should.

2. For Resident #9, the facility staff failed to ensure the resident was wearing a waffle boot as ordered by the Physician, and also failed to ensure that a Dietitian consult was conducted timely as ordered by the Physician. Resident #9 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 5/17/17, indicated the resident had moderate cognitive impairment, required extensive assistance of 2 staff for dressing, was at risk for developing pressure ulcers, had one [MEDICAL CONDITION] present, and had pressure reducing devices for the bed and chair.

a. Review of the resident diabetic wound care plan, revised 5/30/17, indicated the following intervention: use boot to relieve pressure on the heels. Review of the Physician Order Report, dated 7/2017 and signed by the Nurse Practitioner (NP) on 7/3/17, indicated an order for [REDACTED]. During an observation on 7/19/17 at 8:20 A.M., Resident #9 was lying in bed wearing a hospital gown. The resident had an air mattress in place set at 6 bars, and the head of the bed was down. The resident was observed to have regular socks on his/her feet, and no waffle boots as care planned. During an observation/interview on 7/19/17 at 9:10 A.M., Resident #9 was lying in bed with the head of the bed elevated. The resident was watching television. The resident had on regular socks and no waffle boots as care planned. The resident said that he/she used to wear boots on his/her feet but does not anymore. He/she told the surveyor that the booties were in his/her closet. With the resident’s permission, the surveyor opened the resident’s closet and observed one blue bootie on the right hand side of the closet. During an interview on 7/21/17 at 10:55 A.M., CNA #1 said Resident #9 used to wear booties on his/her feet but does not anymore. During an interview on 7/21/17 at 11:50 A.M., UM #1 said the waffle boots were discontinued on 7/20/17 (during the survey), and the order should have been discontinued sooner.

b. Review of the Physician’s Interim Orders, dated 7/12/17, indicated an order for [REDACTED]. Review of the clinical record indicated the last Dietitian note was 3/3/17. During an interview on 7/21/17 at 11: 05 A.M., Regional Nurse #2 said the facility has a Dietitian that provides services for 24 hours on weekly basis. She further said that Dietitian consults should be completed within 5-7 days. The Dietitian would be notified of the Physician order for [REDACTED].>3. For Resident #13, the facility failed to ensure that a Dietitian consult was conducted timely as ordered by the Physician. Resident #13 was admitted to the facility in 8/2007 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 5/25/17, indicated Resident #13 was cognitively intact, had a [DIAGNOSES REDACTED]. Review of the Physicians Interim Orders, dated 7/17/17, indicated an order for [REDACTED]. Review of the clinical record indicated the last Dietitian evaluation was conducted on 5/31/17. During an interview on 7/26/17 at 11:55 A.M., UM #2 said that the Dietitian consult for Resident #13 was not completed because the Dietitian was never notified of the consult

4. For Resident #7, the facility failed to follow a Physician’s order for feeding a resident with gastro-esaphageal reflux disease (GERD). Resident #7 was admitted to the facility in 11/2011 with a [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 4/6/17, indicated the resident was cognitively intact as evidenced by a Brief Interview of Mental Status score of 13 of 15 and was totally dependent for eating.

Review of the 5/2017 Physician’s orders indicated an order for [REDACTED].>Remain upright at 90 degrees during all oral intake and for 45 minutes afterwards. On 7/19/17 at 9:00 A.M. the resident was observed being fed by CNA #3. The resident was in bed in a slumped position with his shoulders raised approximately 30 degrees. CNA #3 said he was feeding the resident breakfast. On 7/19/17 at 9:15 A.M. the resident was observed by the surveyor, accompanied by UM #2. He/she was still in bed, in a slumped position with his/her shoulders raised approximately 30 degrees. UM #2 said the Physician’s order is that the resident must be up 90 degrees when eating.

On 7/19/17 at 10:15 the resident was observed in the same position. The resident told the surveyor he/she had been in this same position throughout breakfast.

5. Based on interview and record review, the facility staff failed to follow a Physician’s order to discontinue medications. Resident #12 was admitted to the facility in 5/2017 with a [DIAGNOSES REDACTED]. Review of a Physician’s order, dated 5/22/17, indicated an order for [REDACTED]. Review of the Medication Administration Records (MAR) for 5/2017, 6/2017 and 7/2017 indicated the Vitamin C and Zinc Sulfate were not discontinued until 7/22/17. On 7/25/17 at 10:00 A.M. during an interview with Nurse #2, he said the medications were ordered for 30 days on 5/22/17 but were not discontinued until 7/22/17.

Failed to make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure that one resident (#1), in a sample of 5 applicable residents, in a total sample of 22 residents received appropriate treatment and services to maintain or improve the ability to carry out activities of daily living.

Findings include:

Resident #1 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 10/5/16, indicated the resident had short and long term memory problems, required extensive assistance for transfers and did not ambulate.

Review of the Certified Nurses’ Aide (CNA) Care Card, updated 5/31/17, indicated the resident was non-ambulatory. Review of the Care Plan for limited physical mobility, edited 6/9/17, indicated a goal for the resident was to perform transfers and gait with limited assistance. The care plan indicated the resident was dependent for transfers and wheelchair mobility. Review of a Physical Therapy (PT) Evaluation and Plan of Treatment indicated a certification period of 6/9/17 through 7/8/17. On discharge, the resident was able to ambulate 200 feet with a rolling walker and moderate assistance. The resident and caregiver staff were given instructional training. Review of the PT Discharge Summary indicated the dates of service were 6/9/17 to 7/7/17. The discharge recommendations indicated continuation of services through an FMP (Functional Maintenance Program) so the resident would maintain their Current Level of Functioning (CLOF), to be done by the nursing staff. The prognosis for the resident to maintain CLOF was excellent with continued staff support.

Review of a Rehab/Nursing Inservice/Education Record, dated 7/5/17, indicated the topic/objective was the resident was to ambulate daily with the CNA staff one time on the 7:00 A.M. to 3:00 P.M. shift and one time on the 3:00 P.M. to 11:00 P.M. shift. The resident could ambulate up to 150 feet with a rolling walker with contact guard assistance and minimal assistance of one, and close wheelchair follow by another person. Must use gait belt. Only one nurse and two CNAs had signed the attendance record for this inservice/education.

Review of the CNA Flow Sheets from 7/5/17 to 7/19/17 indicated the resident had ambulated with staff a total of only four times. There was no way to tell distance, or if the PT recommendations relative to level of assistance had been followed.

During an interview with Unit Manager #1 on 7/19/17 at 3:30 P.M., she said she did not know how ambulation status would be tracked. She said they needed a better system. During an interview with the Rehabilitation Director on 7/19/17 at 4:15 P.M., he said staff were trained by the Rehabilitation Staff during the last few days of treatment. Nursing should carry that education over to other staff. He said he would have expected more of the nursing staff to be trained after reviewing the inservice attendance sheet. In addition, he said if the resident wasn’t ambulating, he would expect that a new referral would be made to PT. He was not aware the resident was not ambulating with the nursing staff.

Failed to make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility staff failed to ensure that 1 sampled resident (#9) received proper treatment and services pertaining to vision care, in a total of 22 sampled residents.

Findings include:

Resident #9 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Ancillary Medical Services form, dated 4/2014, indicated the resident wanted to utilize vision services.

Review of the Appointment/Consultation form, dated 8/4/16, indicated the resident had an eye appointment with the recommendation to follow up in 2 months. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 5/17/17, indicated the resident had impaired vision and did not utilize corrective lenses.

Review of the clinical record did not indicate that a follow up appointment was conducted in 10/2016 for vision. During an interview on 7/25/17 at 9:30 A.M., Unit Manager #1 said Resident #9 did have an eye appointment booked for 10/6/16, but the appointment was canceled because of a transportation issue. She said the appointment was supposed to be re-booked after Social Services resolved the issue, but the appointment was never re-scheduled.

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 observations, interviews and record reviews, the facility failed to ensure adequate supervision, assuasive devices and/or adhere to the resident plan of care to prevent falls for 2 sampled residents (#8 and #10), of 7 applicable residents reviewed for falls, in a total of 22 sampled residents.

Findings include:

1. For Resident #10, the facility staff failed to adequately supervise and provide appropriate interventions when the resident was left alone in the bathroom with no fall prevention measures implemented. Resident #10 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 10/3/16, indicated the resident had moderate cognitive impairment, required limited assistance of 1 staff member for transfers/ambulation, and required extensive assistance of 1 staff member for bathing/dressing and toileting.

Review of the resident falls care plan, revised 12/5/16, indicated that the resident was at risk for falls related to multiple falls at home, gait and balance issues, muscle weakness and decreased vision. The facility implemented the following interventions: bed alarm to alert staff when he/she is trying to get up alone, encourage resident to assume a standing position slowly, encourage resident to use environmental devices (hand grips, hand rails), give verbal reminders not to ambulate/transfer without assistance, provide extensive toileting assistance upon request and with every incontinent episode. Review of the facility Event/Incident Report, dated 12/5/16, indicated the resident experienced an unwitnessed fall at 2:45 P.M. in his/her room. The resident was found by another resident sitting on the floor next to his/her bed. The investigation indicated that the resident was non-compliant with safety precautions, and that the call light was accessible and functioning, but was not activated by the resident at the time of the fall. The intervention added to the resident’s plan of care at this time included a chair alarm. Review of the resident falls care plan, revised 12/19/16, indicated the use of a velcro alarm seat belt to be applied when the resident is in his/her wheelchair to alert the staff when he/she is planning on rising without assistance. Review of the Quarterly MDS Assessment, dated 12/28/16, indicated the resident required extensive assistance of 1 staff for transfers and toileting.

Review of the facility Event/Incident Report, dated 3/4/17, indicated the resident experienced an unwitnessed fall at 12:15 P.M. in his/her bathroom. The resident stated in the investigation that he/she fell asleep while sitting on the toilet and fell . The staff member assigned to the resident at the time of the fall indicated in his/her statement that he/she was toileting another resident when Resident #10 fell , and that the fall could have been prevented if the resident did not stay in the bathroom for so long. The intervention added to the falls care plan at the time of the fall included: assist the resident with toileting.

Review of the resident falls care plan, revised 3/4/17, indicated the following intervention: staff to stay with the resident while he/she is on the toilet. During an interview, on 7/26/17 at 2:15 P.M., Unit Manager (UM) #1 said Resident #10 has poor safety awareness and impulsivity. She further said the resident can be instructed to ring the call bell, but is not always consistent in doing so. UM #1 said that the resident sits in the bathroom and that on 3/4/17, staff left him/her in there where he/she fell asleep and fell . UM #1 said that the safety alarms were not in place at the time of the fall. She said that there is no facility policy that says the residents with alarms for safety reasons cannot be left alone in the bathroom, but said that after the incident staff were instructed to stay with the resident when he/she was being toileted.

2. For Resident #8, the facility staff failed to ensure that fall interventions were implemented as per the plan of care relative to the resident’s personal bag being on his/her person and implementation of a chair alarm.

Resident #8 was admitted to the facility in 1/2015 with [DIAGNOSES REDACTED]. Review of the resident falls care plan, initiated 7/13/15, indicated the resident was at risk for falls related to decreased muscle strength, poor safety awareness and antidepressant medications. Interventions included: keep personal items and frequently used items within reach, give verbal reminders not to ambulate/transfer without assistance.

Review of the Physician order [REDACTED]. Review of the facility Event/Incident Report, dated 3/26/17, indicated the resident experienced and unwitnessed fall in his/her room at 6:45 P.M. The report indicated the resident was observed lying the floor between the bed and the wheelchair. The alarm was on and functioning. The report indicated that the resident was reaching for his/her personal bag which was across the bed and rolled off the bed. The intervention added to the plan of care after the fall included: ensure personal bag is within reach.

Review of the resident falls care plan, revised 3/26/17, indicated for staff to ensure the resident had his/her bag with him/her at all times, and to encourage the use of a reacher. Review of the facility Event/Incident Report, dated 4/25/17, indicated the resident experienced an unwitnessed fall in his/her room at 5:00 A.M. The investigation indicated that the resident was attempting to reach his/her bag, which was not accessible as per plan of care, and was found lying on the floor. The intervention added to the plan of care after the fall included to re-educate staff regarding having essential items within the residents reach. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 6/7/17, indicated the resident had severe cognitive impairment, required extensive assistance of 1 staff for transfers, dressing, toileting and personal hygiene, was non-ambulatory and utilized a wheelchair, and experienced 2 falls with no injury since the last assessment. Review of the Treatment Administration Record (TAR), dated 7/2017, indicated application of a bed and chair alarm at all times and for staff to check placement and function every shift.

Review of the facility Event/Incident Report, dated 7/13/17, indicated the resident experienced an unwitnessed fall in his/her room at 11:15 A.M. The investigation indicated that the resident slid out of his/her wheelchair while reaching for an item on the floor. Further review of the investigation indicated that the chair alarm was not on as ordered. During an observation on 7/21/17 at 8:00 A.M., the resident was seated in wheelchair in the dayroom with other residents. No staff were present. The resident was observed to be dressed and wearing shoes, did not have an alarm box on his/her chair, nor was his/her personal bag with him/her, as care planned. During an interview on 7/21/17 at 9:15 A.M., Certified Nurse Aide (CNA) #1 said Resident #8 uses a bed and chair alarm. When the surveyor asked CNA #1 if the resident had on his/her chair alarm, CNA #1 said that sensor pad was on the resident’s wheel chair, but the alarm box was not, therefore, the alarm would not sound if the resident attempted to stand up.

During an interview on 7/21/17 at 9:25 A.M., Unit Manager (UM) #1 said the CNAs check resident alarms on rounds. Nurses document in the treatment record that the alarms are in place. She said the resident has had falls because he/she tends to reach for his/her personal bag. The surveyor asked UM #1 if the resident currently had his/her personal bag with him/her as care planned, and UM#1 said he/she did not have it but should.

Failed to give or get specialized rehabilitative services per the patient's assessment or plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility staff failed to ensure that a Physical Therapy evaluation was completed timely when ordered by the Physician for 1 sampled resident (#9), in a total sample of 22 residents.

Findings include:

Resident #9 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 5/17/17, indicated the resident did not ambulate, required extensive to total assistance of staff for dressing, bathing and personal hygiene, and utilized a wheelchair. Review of the Physician’s Interim Orders, dated 7/12/17, indicated an order for [REDACTED].

Review of the clinical record indicated the last PT evaluation was conducted on 1/21/16. Further review of the clinical record indicated the last OT evaluation was conducted on 2/21/17, with an OT screen completed on 5/12/17. During an interview on 7/21/17 at 11:05 A.M., Regional Nurse #2 said that PT and OT evaluations should be conducted within 2-3 days of receiving the physician’s orders [REDACTED].>During an interview on 7/21/17 at 11:55 A.M., the Director of Rehabilitation said that when the Physician orders [REDACTED]. He further said to Unit Manager #1 with the surveyor present, that when an order for [REDACTED].

Review of the PT Evaluation, dated 7/21/17 indicated the resident would benefit from skilled PT services.

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 interviews, facility staff failed to ensure the clinical record was accurately documented and complete for 1 of 2 Non-Sampled Residents (NS #2)

Findings include:

For NS #2, nursing staff failed to ensure the clinical record was accurately recorded related to [MEDICATION NAME] injections (injectable blood thinning medication). NS #2 was admitted to the Facility in 4/2016 with [DIAGNOSES REDACTED]. During the medication pass with Nurse #2 on 7/19/17 at 8:58 A.M., the Surveyor observed Nurse #2 administer a [MEDICATION NAME] injection into the Resident’s left lower/middle aspect of the abdomen appropriately. Nurse #2 then documented a check mark on the Medication Administration Record (MAR) indicating that he administered the injection in the Right(R)/(L) Left arm, which he did not.

During interview, directly after what had been observed and documented on the MAR on 7/19/17 at 9:02 A.M., the Surveyor asked Nurse #2 where he just administered the [MEDICATION NAME], to which Nurse responded the left abdomen. The Surveyor then asked Nurse #2 why he documented he administered the [MEDICATION NAME] into the arm, inaccurately. The Surveyor then observed that there were several entries by other Licensed Nurses indicating the [MEDICATION NAME] had been administered in the R/L arm. Nurse #2 said, that is not correct. He said [MEDICATION NAME] must be administered in the abdomen and rotated for proper absorption. Nurse #2 said that the other nurses must have mistakenly documented the injection site as being the arm, just as he did.

Further review of the MAR indicated that NS #2 received [MEDICATION NAME] in the R/L arm on 7/3, 7/9, 7/11, 7/13, 7/15 and for this mornings dose on 7/19/17 at 9:00 A.M. After pointing this out to Nurse #2, Nurse #2 circled the check mark he documented inaccurately for the arm, then proceeded to cross out the entry indicating the injection site for the arm, thus altering the clinical record where several other Licensed Nurses had documented. Nurse #2 said that he should not have crossed out the entry, and would reprint the correct information in the computer to ensure the R/L arms were not an option for injection sites, and would alert the Supervisor he altered the record in haste.

Wingate at Sudbury, 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.

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Sources:

Medicare Nursing Home Profiles and Reports – Wingate at Sudbury

Inspection Report for Wingate at Sudbury – 07/26/2017

Page Last Updated: August 10, 2018

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