The Reservoir Center for Health and Rehabilitation

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

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

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About The Reservoir Center for Health and Rehabilitation

The Reservoir Center for Health and Rehabilitation is a for profit, 144-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Marlborough, Hudson, Southborough,  Northborough, Westborough, Sudbury, Maynard, Clinton, Ashland, Framingham, and the other towns in and surrounding Middlesex County, Massachusetts.

The Reservoir Center for Health and Rehabilitation
400 Bolton St
Marlborough, MA 01752

Phone: (508) 481-6123
Website: http://reservoircenterrehab.com/

CMS Star Quality Rating

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

As of 2018, The Reservoir Center for Health and Rehabilitation in Marlborough, 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 3 out of 5 (Average)

Fines Against The Reservoir Center for Health and Rehabilitation

The Federal Government has not fined The Reservoir Center for Health and Rehabilitation in the last 3 years..

Fines and Penalties

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to incorporate the resident’s choice regarding advance directives on to the Medication Administration Record [REDACTED].

Findings include:

Resident #16 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/4/17, indicated in Section S that the resident was Do Not Resuscitate (DNR), Do Not Hospitalize (DNH) and Do No Intubate (DNI).

Review of the Physician Orders, dated 12/30/16, indicated an order that the resident was DNR/DNH/DNI. Review of the Doctor’s Progress Notes, dated 12/30/16, indicated the resident was DNR/DNI/DNH. Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated 12/30/16, indicated the resident was Do Not Resuscitate, Do Not Intubate and Do Not Transfer to Hospital. Review of the signed monthly Physician Orders, dated January 2017, indicated the resident was a Full Code.

Review of the January 2017 MAR, indicated the resident was a Full Code. During an interview, on 1/18/17 at 2:00 P.M., Nurse #1 said the January 2017 MAR indicated [REDACTED].

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to: a) complete Nurse Aide Registry Checks timely for 5 of 5(#1, #2, #3, #4 and #5) sampled new employees reviewed b) failed to complete a Criminal Offender Record Information(CORI) check for 1 of 5(#2) sampled new employees reviewed c) failed to check the State Licensing Board for 3 of 3 (#1, #2 and #3) sampled new employees Licensed Practical Nurses(LPN) to ensure that they not employ individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law or who have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED].

Findings include:

Review of the facility policy for Abuse, revised 11/16, indicated the following for screening new employees: All potential employees will be screened for any history of abuse, neglect or mistreatment of [REDACTED]. Screening shall include, but is not limited to:

-At least one favorable reference from previous or current employers
-Checking and verifying licenses
-checking and verifying CNA registry (this includes all departments)
-checking OIG listing

a) For the following new employees the State Nurse Aid Registry checks were not completed timely: -New employee #1 was hired on 10/6/16 and the CNA registry check was completed on 10/29/16 -New employee #2 was hired on 10/19/16 and there was no documentation from the CNA registry found or provided in the new employee file. A CNA registry check was completed on 1/17/16 after surveyor inquiry -New employee #3 was hired on 10/28/16 and the CNA registry check was completed on 10/29/16 -New employee #4 was hired on 11/11/16 and the CNA registry check was completed on 12/6/16 -New employee #5 was hired on 11/29/16 and the CNA registry check was completed on 12/6/16 During interview with the Facility Coordinator on 1/17/16 at 8:40 A.M. she said that CNA registry checks are completed on all new employees and the CNA registry checks were completed late as noted.

b) For new employee #2 the CORI check was not completed. New employee #2 was hired on 10/19/16 and a signed consent undated for the CORI check was in the new employee file. During interview with the Facility Coordinator on 1/17/16 at 12:00 P.M. she said that although the consent was obtained the CORI check was not completed.

c) For new employees #1, #2 and #3 all LPNs the Licensing Board was not checked to ensure that they did not have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].

During interview with the Facility Coordinator on 1/17/16 at 12:00 P.M. she said that the licenses are verified by obtaining a copy of the license from the employee. The licenses are not verified online at the Board of Registry in Nursing.

Failed to provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to provide a privacy bag for one sampled resident (#2) in a total sample of 24 residents.

Findings include:

Resident #2 was admitted to the facility in 4/2009, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/23/16, indicated in section H0100, that the resident utilized an indwelling catheter. During an observation, on 1/17/17 at 9:45 A.M., the resident was lying in bed and had a Foley catheter (tube inserted into the bladder for urine collection) bag and tubing lying on the bed. The Foley bag was not in a privacy bag. The resident did have a roommate in his/her room. The privacy curtain between the two beds was not drawn. The surveyor could visualize the drainage bag upon entering the room.

Failed to provide housekeeping and maintenance services.

Based on observation and interview, the facility staff failed to maintain a sanitary, orderly and comfortable interior for 3 out of 4 units.

Findings include:

1. During the environmental rounds on the East 1 Unit, on 1/20/17 at 9:15 A.M., with the Maintenance Director, the following was observed:

-Room 122 had brown stains on the ceiling.
-The toilet in the bathroom between Rooms 121-122 had a brown ring on the floor around the base of the toilet. The frames of both doors leading out of the bathroom had chipped paint.
-Room 123 had one wall with chipped paint. The heater in the room had long, black lines. 3 floor tiles in the room were chipped. The wallpaper behind the headboard was ripped the whole length of the headboard.
-Both door frames of the bathroom between Rooms 123-124, had chipped paint.
-The bathroom between Rooms 125-126 had brown stains on the floor in front of the toilet.
-The bathroom door frame from Room 125 had chipped paint on the bottom of the frame.
-Room 126 had ripped wallpaper behind the headboard of Bed A.
-The Shower Room on the unit had a door frame with chipped paint.
-Chipped floor tiles were observed at end of the unit hallway.
-The bathroom between Rooms 132-133 had chipped paint on the door frame.
-Room 132 had wallpaper peeling on the bottom of the wall behind Bed B. In addition, there were holes in the upper wall by the headboard.
-The toilet between Rooms 130-131 had a brown ring on the floor around the base of the toilet.
-Room 129 had several missing tile pieces above the heater. The missing tiles extended the length of the heater which exposed yellow material.
-The specimen refrigerator in the Soiled Utility Room on the East 1 unit used to store specimens for the laboratory was registering a temperature of above 60 degrees. There was a urine specimen in the refrigerator. The inside of the refrigerator was warm. Not maintaining the temperature correctly can cause bacteria to grow in the specimen. During an interview, on 1/20/17 at 11:00 A.M., Nurse #1 said she tripped the specimen refrigerator and it is now working. Nurse #1 said the 11:00 P.M.-7:00 A.M. staff is responsible to check the specimen refrigerator temperature nightly and log the temperature in the 11:00 P.M.-7:00 A.M. black binder.

During an interview, on 1/20/17 at 11:05 A.M., the Assistant Director of Nurses (ADON) said the 11:00 P.M.-7:00 A.M. shift staff check the specimen refrigerator temperature nightly and log the temperatures into the 11:00 P.M.-7:00 A.M. black binder. During an interview, on 1/20/17 at 12:40 P.M., the ADON said there was no specimen refrigerator temperature logs in the 11:00 P.M. -7:00 A.M. black binder. During an interview, on 1/20/17 at 12:45 P.M., the Maintenance Director said he was not aware of staff being able to trip the specimen refrigerator when it was not working properly and he would be looking into the matter immediately. During an interview, on 1/20/17 at 9:45 A.M., the Maintenance Director said he would take the specimen refrigerator out of service.

2. During the environmental rounds of the West 1 Unit, on 1/20/17 at 10:00 A.M., with the Maintenance Director, the following was observed:
-The bottom of the heater in Room 110 had chipped paint.
-The bottom of the heater in Room 111 had chipped paint. There were brown stains on the ceiling. The wall behind Bed B had a large piece of wallpaper missing and also had peeling wallpaper.
-Room 112 had large brown stains on the ceiling.
-Room 115 had a heater with chipped paint.
-Room 117 had large brown stains on the ceiling extending from the window to the middle of the room. There was torn wallpaper behind Bed A.
-Room 101 had a heater with chipped paint. -Room 102 had a ceiling with chipped paint. In the back of the headboards of Bed A and Bed C there were large pieces of missing wallpaper.
-Room 106 had brown stains on the ceiling.
-Room 107 Bed A had a large piece of wallpaper missing behind the headboard. In addition, there were areas with chipped wall observed behind the headboard.
-Room 108 had a large piece of wallpaper missing behind the headboard of Bed A.

3. During the environmental rounds on the West 2 Passport Unit, on 1/20/17 at 10:25 A.M., with the Maintenance Director, the following was observed: -Room 211 had a wall with a long line of chipped paint. During an interview , on 1/20/17 at 12:45 P.M., the Maintenance said he would be addressing the areas of concern noted during the tours.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to implement a comprehensive care plan for Dressing, Bathing and Hygiene, for one sampled resident (#16), out of a total sample of 24 residents.

Findings include:

Resident #16 was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) Care plan, dated 12/28/16, indicated there was an ADL care plan in place with no information relative to dressing, hygiene and bathing.

Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/4/17, indicated the resident required extensive assist of one staff for dressing, bathing and hygiene. Review of the Comprehensive Care Plan Record of Team Meetings form, indicated a care plan meeting was held on 1/16/17.

Review of the Social Service Notes on 1/18/17, indicated an entry dated 1/19/17 (future date), that a care plan meeting was held with team and all care plans were reviewed and updated.

During an interview, on 1/18/17 at 8:30 A.M., the Director of Nurses (DON) said the entry in the Social Service Notes, dated 1/19/17, was incorrect and a care plan meeting was to take place on 1/18/17.

Failed to allow the resident the right to participate in the planning or revision of the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to review and revise the resident plan of care during the quarterly assessments, as required, for 1 sampled resident (#3), in a total of 24 sampled residents.

Findings include:

Resident #3 was admitted to the facility in 11/2015, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 5/18/16, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (indicating severe cognitive impairment), utilized a wheel chair, received no scheduled or as needed (PRN) doses of pain medication, was on a mechanically altered diet, and did not receive services from Speech Language Pathology or Physical Therapy during the assessment period.

Review of the Swallowing strategies form, dated 2/18/16, indicated the resident’s diet texture was: Mechanical soft solids, thin liquids, and that the resident required close supervision at meals due to decreased cognition/impulsivity.

Review of the signed physician’s orders [REDACTED]. Review of the resident’s Pain care plan,(initiated 11/9/15), indicated a revision date of 5/2016.

Review of the the resident’s Dehydration/Fluid Maintenance care plan, (initiated 11/9/15), indicated a revision date of 5/2016.

Review of the resident’s Physical Restraints/Positional Device care plan, (updated 3/3/16), indicated a revision date of 5/20/16

Review of the Comprehensive Care Plan Record of Team Meeting form, indicated that the resident had Quarterly meetings on 2/24/16 and 5/18/16. Further review of the form, did not indicate quarterly meetings were held after 5/18/16.

On 1/13/17 at 7:34 A.M., the surveyor observed the resident seated near the nurses station, in a tilted back wheel chair. The resident was observed to have non-skid socks on both his/her feet and had bilateral leg rests on. During an interview, on 1/13/17 at 9:30 A.M., the Staff Development Coordinator (SDC) said that care plans meetings are held quarterly, every 10-12 weeks. The SDC said that the care plans that are located in the chart are the active care plans.

During an interview, on 1/13/17 at 9:30 A.M., the Director of Nurses (DON) said that the care plan meetings are documented on the Care Plan Record of Team Meeting form, and the last documented care plan meeting for the resident was 5/18/16. The DON said that there was no indication that care plan meetings were held in 8/2016 and 11/2016, as required.

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 interview, the facility staff failed to provide services in accordance with nursing standards of practice for 1 resident, (#22), as evidenced by a) inaccurate transcription of a Physician order [REDACTED]. b) failing to indicate the specific reason and result/effectiveness for each dose of a medication administered on an as needed (PRN) basis in a total sample of 24 residents.

Findings include:

For Resident #22 the facility failed to administer the medication [MEDICATION NAME] in the correct dose as ordered by the Physician and failed to indicate the specific reason and result/effectiveness for each dose administered of a medication ordered on an as needed basis.

Review of the completion instructions for the facility 2 sided Medication Administration Record [REDACTED]. Resident #22 was admitted to the facility 8/2016 with [DIAGNOSES REDACTED].

Review of the interim Physician orders [REDACTED].

-on 9/14/16 may admit to Hospice

-on 11/30/16 [MEDICATION NAME] ([MEDICATION NAME] narcotic [MEDICATION NAME]) 20 milligrams(mg)/ milliliter(ml) give 5 mg (0.25 ml) sublingually(SL) every hour PRN for shortness of breath/pain

-on 11/30/16 [MEDICATION NAME] (antianxiety medication) 0.5 mg SL every hour PRN Review of the December Medication Administration Record [REDACTED]. The entry was initialed as administered 3 times on 12/1/16. There was a written notation across the entry that read, discontinued 12/1/16, see new order. The next page of the December MAR indicated [REDACTED]. This entry did not include the dose to be given in mg but had the amount 0.5 ml which would equal 10mg and not the 5 mg as ordered by the physician. The entry was initialed as administered 7 times on 12/1/16. Review of the Notes side of the December MAR indicated [REDACTED].

During interview with the Director of Nurses (DON) on 1/17/16 at 1:15 P.M. he said that the Physicians order dated 11/30/16 for the resident to receive [MEDICATION NAME] 5 mg SL every hour PRN for shortness of breath/pain was not transcribed on the December MAR indicated [REDACTED].

Further review of the December MAR indicated [REDACTED]. There was no documentation indicating the medication had been administered to the resident. Review of the facility narcotic book revealed that the resident had received 4 doses of the PRN medication [MEDICATION NAME] on 12/1/16.

During interview with the DON on 1/17/16 at 1:15 P.M. he said that the December MAR indicated [REDACTED]. He further said that there was no documentation for the reason and effect of the PRN medication doses administered.

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, staff interviews and record reviews, the facility staff failed to follow the plan of care for 6 sampled residents (#1, #5, #7, #13, #17, and #24), in a total of 24 sampled residents.

Findings include:

1. For Resident #24, the facility staff failed to administer [MEDICATION NAME] (a medication used to stabilize mood), as prescribed by the physician. Resident #24 was admitted to the facility in 7/2016, with [DIAGNOSES REDACTED]. Review of the Doctor’s Progress Notes, dated 10/25/2016, indicated an order to start [MEDICATION NAME] 125 (no unit specified) twice daily. Review of the Physician/Prescriber Telephone Orders, dated 10/25/16, indicated an order for [REDACTED]. Review of the signed monthly physician’s orders [REDACTED].>Review of the Medication Administration Record [REDACTED] During an interview, on 1/20/17 at 2:15 P.M., the Director of Nurses (DON) said that the order for [MEDICATION NAME] was not on the MAR for 11/2016.

2. For Resident #17, the facility staff failed to administer [MEDICATION NAME] (an antiflatulent medication) and a fluid restriction, as ordered by the physician. Resident #17 was admitted to the facility in 3/2014, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/8/16, indicated that the resident had an Ostomy, had active [DIAGNOSES REDACTED]. Review of the Nurse’s Notes, dated 12/17/16, indicated the Physician ordered the resident to be transferred to the hospital for evaluation of [MEDICAL CONDITION]. Review of the Nurse’s Notes, dated 12/21/16, indicated the resident was readmitted to the facility after hospitalization for [MEDICAL CONDITION]. Review of the physician’s Readmission note, dated 12/22/16, indicated an order for [REDACTED]. Review of the Physician/Prescriber Telephone Orders, dated 12/22/16, indicated an order for [REDACTED]. Review of the 12/2016 MAR, indicated no order for a fluid restriction to be administered. Review of the signed physician’s orders [REDACTED]. Further review of the MAR, indicated no order for [MEDICATION NAME] 80 mg to be administered three times daily. On 1/18/17 at 10:10 A.M., the surveyor observed Resident #17 standing in front of the nurses station, wearing socks on his/her feet, and a shirt that exposed an Ostomy bag located in his/her left lower abdomen. During an interview, on 1/18/17 at 10:20 A.M., Nurse #1 said that the resident was readmitted from the hospital in 12/2016, and had an order to resume [MEDICATION NAME] 80 mg three times daily, but the order was not put on the current MAR. Nurse #1 further said the the order for the fluid restriction was not put on the MAR indicated [REDACTED]

3. For Resident #7, the facility staff failed to follow the plan of care relative to the air mattress setting to be set at 150 pounds (lbs), as ordered by the physician. Resident #3 was admitted to the facility in 7/2016, with [DIAGNOSES REDACTED]. Review of the Skin at Risk-Pressure Stasis Care Plan, dated 8/31/16, indicated the resident had a low air loss mattress, with the setting to be at 150 lbs, and for staff to check the setting and function every shift. Review of the Quarterly MDS Assessment, with an ARD of 10/27/16, indicated that the resident was at risk for developing pressure ulcers, had a surgical wound, and had a pressure reducing device for the bed. Review of the signed physician’s orders [REDACTED]. Review of the current physician’s orders [REDACTED].On 1/12/17 at 1:25 P.M., the surveyor observed the resident lying in bed with his/her eyes closed. The surveyor observed the air mattress setting to be set at 325 lbs. On 1/12/17 at 3:30 P.M., the surveyor observed the resident lying in bed with his/her eyes closed. The surveyor observed the air mattress setting to be set at 325 lbs. On 1/13/17 at 7:30 A.M., the surveyor observed the resident lying in bed with his/her eyes open. The surveyor observed the air mattress setting to be set at 325 lbs. On 1/18/17 at 8:30 A.M., the surveyor observed the resident lying in bed with his/her eyes open. The surveyor observed the air mattress setting to be set at 150 lbs. During an interview on 1/18/17 at 8:30 A.M., Nurse #2 said that the air mattress setting is to be set at 150 lbs.

4. For Resident #1, the facility staff failed to ensure proper air mattress setting. Resident #1 was admitted to the facility in 5/2016, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 11/22/16, indicated the resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Further review of the MDS, indicated in Section M1200, that the resident utilized a pressure reducing device for bed. Review of the monthly Physician Orders, dated 1/01/17, indicated an order for [REDACTED]. Review of the Treatment Record, dated 01/01/17, indicated that the Relief Low Air Loss Mattress System, Standard Mode, Setting at 26- Check Setting and Function was signed off for each shift: 11:00 P.M. -7:00 A.M., 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M. Review of the Pressure Ulcer Comprehensive Care Plan, dated (6/13/16), indicated a Pressure redistribution mattress, Relief Low Air Standard Mode setting to be at 260 (no unit specified).

During an observation, on 1/12/17 at 1:30 P.M., the resident was resting in bed with eyes closed. The air mattress setting was set at 220. During an observation, on 1/13/17 at 2:10 P.M., the resident was lying in bed. The air mattress setting was set at 220. During an observation, on 1/17/17 at 8:30 A.M., the resident was eating breakfast in bed. The air mattress setting was set at 220. During an observation, on 1/20/17 at 8:07 A.M., the resident was in bed watching television. The air mattress setting was set at 220. During an interview, on 1/20/17 at 8:30 A.M., the Staff Development Coordinator (SDC) said the Physician order [REDACTED].

5. For Resident #5, the facility staff failed to ensure proper air mattress setting. Resident #5 was admitted to the facility in 4/2012, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 12/16/16, Section M1200, indicated the resident utilized a pressure reducing device for bed. During an observation, on 1/13/17 at 1:30 P.M., the resident was not in his/her room, and his/her air mattress was set at 200. During an observation, on 1/17/17 at 8:30 A.M., the resident was sitting up in bed and eating breakfast. The air mattress setting was set at 200. During an observation, on 1/17/17 at 2:20 P.M., the resident was resting in bed. The air mattress setting was set at 200. Review of the signed Monthly Physician Orders, dated 01/01/17, indicated an order for [REDACTED]. Review of the Monthly Treatment Orders, dated 01/01/17, indicated an order for [REDACTED]. During an interview, on 1/17/17 at 2:40 P.M., Nurse #3 said the setting on the air mattress was incorrect and it should be at 250.

6. For Resident #13, the facility staff failed to obtain an order for [REDACTED].>Resident #13 was admitted to the facility in 6/2016, with [DIAGNOSES REDACTED].#5 and cervical disk #7, and failure to thrive. Review of the Quarterly MDS Assessment, with an ARD of 11/22/16, indicated in Section M1200, that the resident utilized a pressure reducing device for the bed. Review of Section M0300, indicated that the resident had one stage 3 pressure ulcer and 2 stage 4 pressure ulcers. Review of the Pressure Ulcer Comprehensive Care Plan, dated 6/22/16, indicated to utilize an air mattress A/O (as ordered). Review of the signed monthly Physician Orders, dated 1/1/17, indicated an order for [REDACTED]. Review of the January 2017 Treatment Record, indicated an order for [REDACTED]. During an observation, on 1/13/17 at 2:30 P.M., the resident was lying in bed with eyes closed and the air mattress was set at 150. During an observation, on 1/17/17 at 8:05 A.M., the resident was awake in bed, watching television. The air mattress was set at 150. During an observation, on 1/17/17 at 8:15 A.M., the resident was in bed and the air mattress setting was at 150. During an interview, on 1/17/17 at 8:20 A.M., Nurse #4 said the setting was incorrect and she changed it to 100. She said the setting is based on the resident’s weight. During an interview, on 1/20/17 at 8:10 A.M., Unit Manger #1 said she needed to call the physician for a clarification order regarding the air mattress setting.

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 observation, interview and record review, the facility staff failed to ensure that 1 sampled resident (#3) was free from duplicate medication therapy, in a total of 24 sampled residents.

Findings include:

Resident #3 was admitted to the facility in 11/2015, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 5/18/16, indicated that the resident had impaired vision and had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (indicating severe cognitive impairment).

Review of the signed physician’s orders [REDACTED]. On 1/12/17 at 3:20 P.M., the surveyor observed Resident #3 lying in a low bed with his/her eyes closed. Bilateral 1/4 side rails were observed to be up and the bed was lowered to the floor.

During an interview on 1/13/17 at 9:30 A.M., the Staff Development Coordinator (SDC) said that the physician reviews the resident medications. The SDC said that the nurses check the orders monthly and first nurse and second nurse note the orders. The SDC said that if a nurse sees a duplicate order, they would contact the physician to ask if the medication is going to be continued. The SDC said that there is no indication that the physician was updated regarding the duplicate orders for the prescribed eye vitamins.

Failed to make sure that residents are safe from serious medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to ensure residents are free of significant medication errors for 1 resident (#22) in a total sample of 24 residents.

Findings include:

For Resident #22 the facility failed to administer the medication [MEDICATION NAME] ([MEDICATION NAME] narcotic [MEDICATION NAME]) in the correct dose as ordered by the Physician. Resident #22 was admitted to the facility 8/2016 with [DIAGNOSES REDACTED]. Review of the interim Physician orders [REDACTED].

-on 9/14/16 may admit to Hospice
-on 11/30/16 2 [MEDICATION NAME] 20 milligrams(mg)/ milliliter(ml) give 5 mg sublingually(SL) every hour as needed (PRN) for shortness of breath/pain On 12/1/16 an additional Physician order [REDACTED].

Review of the December Medication Administration Record [REDACTED]. The entry was initialed as administered 3 times on 12/1/16. There was a written notation across the entry that read, discontinued 12/1/16, see new order. The next page of the December MAR indicated [REDACTED]. The entry was initialed as administered 7 times on 12/1/16. This entry did not include the dose to be given in mg but had the amount 0.5 ml which would equal 10mg and not the 5 mg as ordered by the physician.

The Physicians order dated 12/1/16 for the resident to receive the medication [MEDICATION NAME] 20mg/ml give 10mg SL 0.5 ml every 2 hours was transcribed onto the December MAR indicated [REDACTED]. This entry was initialed as administered 2 times on 12/1/16. During interview with the Director of Nurses (DON) on 1/17/16 at 1:15 P.M. he said that the Physicians order was for the resident to receive [MEDICATION NAME] 5 mg SL every hour PRN and the resident was administered 10 mg per dose in error on 12/1/16.

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

Based on observation and interview the facility failed to monitor the temperature of the refrigerators in the Nourishment refrigerators on two of four units, to ensure that food was stored at the proper temperature.

Findings include:

1. During the environmental tour of the West 1 Unit, on 1/20/17 at 10:00 A.M. with the Maintenance Director it was observed .On the West 1 unit the facility failed to monitor the temperature of the refrigerator and ensure that food was stored at the correct temperature. The refrigerator in the Nourishment Kitchenette had a broken thermometer. During an interview, on 1/20/17 at 10:20 A.M., the Maintenance Director said that he would replace the broken thermometer in the Nourishment Kitchenette refrigerator.

2. During the environmental rounds on the East 2 Unit, on 1/20/17 at 10:40 A.M., with the Maintenance Director, the following was observed: -The refrigerator in the Nourishment Kitchenette had a broken thermometer. During an interview, on 1/20/17 at 10:55 A.M., the Maintenance Director said he would replace the broken thermometer in the refrigerator in the Nourishment Kitchenette.

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

Based on observations and staff interviews, the facility staff failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy, on 2 of 4 units observed.

Findings include:

Per the Nursing 2016 Drug Handbook, open vials of Humalog Insulin must be discarded after 28 days. 1a. During an inspection of the East Meadows Team A medication cart, on 1/13/17 at 9:45 A.M., the following was observed:

-One opened vial of Humalog insulin, with no open date listed on the vial.
-One opened vial of Humalog insulin, with an unclear open date listed on the vial.
-One vial of Humalog insulin, with an open documented date of 12/23/16, but the name of the resident was not legible.

There was no documentation to indicate how long the vials had been open on 2 of the 3 vials. During an interview, on 1/13/17 at 10:00 A.M., Nurse #5 said the 3 vials of Humalog insulin would be discarded.

b. During an inspection of the East Meadows Team B medication cart, on 1/13/17 at 10:20 A.M., the following was observed: -One vial of Humulin R insulin for a specific resident, with an unclear open and discard date written on the vial. During an interview, on 1/13/17 at 10:25 A.M., Nurse #1 said she would discard the vial of insulin.

2a. During an inspection of the West Meadows medication cart Team A, on 1/13/17 at 11:00 A.M., the following was observed: -One open vial of Humulin N insulin for a specific resident, with no open date listed. -One opened tube of Clobetasol Propionate Cream (cream used on the skin) for a specific resident, with an expiration date of 3/2016. During an interview, on 1/13/17 at 11:05 A.M., Nurse #6 said she would discard the Humulin N insulin and Clobetasol Propionate Cream.

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 observations, interviews and record reviews, the facility staff failed to maintain an accurate and complete medical record for 4 sampled residents (#3, #4, #6 and #18), in a total of 24 sampled residents.

Findings include:

1. For Resident #3, the facility staff failed to maintain an updated and accurate resident Admission Record form. Resident #3 was admitted to the facility in 11/2015, with [DIAGNOSES REDACTED]. Review of the Admission Record form, dated 11/19/2015, indicated that the resident was his/her own responsible party. Review of the Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 1/18/16, indicated that the resident lacked capacity to make or to communicate health care decisions relative to progressive dementia, and that the duration of the resident’s incapacity is life long. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/15/16, indicated that the resident had a Brief Interview of Mental Status (BIMS) score of 1 out of 15 (indicating severe cognitive impairment), had an active [DIAGNOSES REDACTED].

On 1/13/17 at 7:34 A.M., the surveyor observed Resident #3 seated at the nurses station, in a tilted back wheel chair, with bilateral leg rests on. The resident was well groomed, and was wearing non-skid socks on his/her feet.

During an interview, on 1/20/17 at 2:15 P.M., the Director of Nurses (DON) said that the face sheet was not accurate. He further said that the face sheets should be updated annually, and with any significant changes.

2. For Resident #4, the facility staff failed to maintain an updated and accurate resident Admission Record Form. Resident #4 was admitted to the facility in 12/2015, with [DIAGNOSES REDACTED]. Review of the Admission Record form, dated 12/21/15, indicated the resident was his/her own responsible party. Further review of the form, did not indicate information on the resident’s diagnoses. Review of the Admission MDS Assessment, with an ARD of 12/25/15, indicated the resident had a BIMS score of 0 out of 15 (indicating severe cognitive impairment), and had [DIAGNOSES REDACTED].

Review of the Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 1/5/16, indicated that the resident lacked capacity to make or to communicate health care decisions relative to dementia, and that the duration of the resident’s incapacity is indefinite.

On 1/18/17 at 3:30 P.M., the surveyor observed the resident seated in a high back wheel chair near the nurses station. The resident had non-skid socks on both his/her feet. During an interview, on 1/20/17 at 2:15 P.M., the DON said that the face sheet was not accurate. He further said that the face sheets should be updated annually, and with any significant changes.

3. For Resident #6, the facility staff failed to maintain an updated and accurate resident Admission Record form. Resident #6 was admitted to the facility in 2/2015, with [DIAGNOSES REDACTED].

Review of the Admission Record form, dated 2/19/15, indicated the resident was his/her own responsible party. Further review of the form, did not indicate information on the resident’s diagnoses. Review of the Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, dated 3/16/15, indicated that the resident lacked capacity to make or to communicate health care decisions relative to progressive dementia, and that the duration of the resident’s incapacity was life long. Review of the Annual MDS Assessment, with an ARD of 2/05/16, indicated the resident had a BIMS score of 3 out of 15 (indicating severe cognitive impairment), had [DIAGNOSES REDACTED].

On 1/13/17 at 1:45 P.M., the surveyor observed Resident #6 seated in a wheel chair, by the nurses station. The resident had a cushion on his/her wheelchair, was well groomed in appearance, and was wearing sneakers. During an interview, on 1/20/17 at 2:15 P.M., the DON said that the face sheet was not accurate. He further said that the face sheets should be updated annually, and with any significant changes.

4. For Resident #18, the facility staff failed to complete the Bladder Assessment form. Resident #18 was admitted to the facility in 3/2015, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, with an ARD of 11/22/16, indicated the resident was continent of bladder. Review of the Bladder Assessment form, undated and unsigned, indicated the assessment was blank. Further review of the quarterly follow up, dated 6/17/16, 8/23/16 and 11/15/16, indicated the assessment remains appropriate. During an interview, on 1/20/17 at 1:00 P.M., the DON said the bladder assessment should have been completed.

The Reservoir Center for Health and Rehabilitation, Nursing Home Neglect and Elder Abuse Lawyers

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

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

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

Boston Personal Injury Lawyers for Elder Abuse Cases

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


Sources:

Medicare Nursing Home Profiles and Reports – The Reservoir Center for Health and Rehabilitation

Inspection Report for The Reservoir Center for Health and Rehabilitation – 01/20/2017

Page Last Updated: May 14, 2018

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