Wingate at Springfield Rehabilitation and Skilled Nursing

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About Wingate at Springfield Rehabilitation and Skilled Nursing

Wingate at Springfield Rehabilitation and Skilled Nursing is a for profit, 120-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of East Longmeadow, Longmeadow, Agawam, West Springfield, Wilbraham, Ludlow, Chicopee Somers, CT Holyoke,and the other towns in and surrounding Hampden County, Massachusetts.

Wingate at Springfield Rehabilitation and Skilled Nursing focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Wingate at Springfield Rehabilitation and Skilled Nursing
215 Bicentennial Highway
Springfield, MA 01118

Phone: (413)796-7511
Website: https://wingatehealthcare.com/location/wingate-at-springfield/

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 2017, Wingate at Springfield Rehabilitation and Skilled Nursing in Springfield, Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Wingate at Springfield Rehabilitation and Skilled Nursing

The Federal Government fined Wingate at Springfield Rehabilitation and Skilled Nursing $1,800 on January 1st, 2015, $17,745 on February 18th, 2016 and $72,488 on April 19th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Lawyers inspected government records and discovered Wingate at Springfield Rehabilitation and Skilled Nursing committed the following offenses:

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

Based on review of personnel files, the Facility staff failed to perform the required pre-screening background checks for 3 of 5 newly hired employees (#1, #2 and #3).

Findings include:

1) Review of the Facility’s Abuse Policy indicated, SCREENING:
– Criminal Background Checks are to be done on every new employee.
– Prior to employment, The Nurse Aide Registry is checked for all facility Hires.
– If the applicant indicates employment or residence in another state, that Nurse Aide Registry is to be checked.
– Previous employment references are checked.
– All professional and certified licenses are verified for expiration date and any outstanding complaints, prior to hire and at the time of each license renewal.

2) Review of the Personnel Files indicated the following:
a. Employee #1 was hired on 8/4/16, as a receptionist. Review of the personnel file indicated no evidence that a Nurse Aide Registry check was completed prior to hire, to ensure there were no findings against this employee.
b. Employee #2 was hired on 8/9/16, as a Licensed Practical Nurse (LPN). The Nurse Aide Registry check, was completed on 8/9/16, the date of hire and not prior to employment to ensure there were no findings against this employee. The Criminal Offender Record Information (CORI), was requested on 8/10/16, and not prior to employment. The LPN license was verified on 10/17/16, and not prior to hire, per the Facility’s Abuse Policy.
c. Employee #3 was hired on 9/13/16, as a Certified Nursing Aide (CNA). Review of the personnel file indicated that the Nurse Aide Registry check was completed on 10/17/16, and not prior to employment, to ensure there were no findings against this employee. During an interview with the Administrator and the Human Resource Specialist, on 11/3/16 at 2:50 P.M., they said that the Nurse Aide Registry checks, the CORI checks, and the License verifications should have been completed prior to the date of hire. Please refer to F496.

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 observation, record review and staff interview, the Facility staff failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident’s status for 1 sampled residents (#5), out of a total sample of 22 residents.

Findings include:

For Resident #5, the Facility staff failed to ensure the annual MDS assessment accurately reflect the resident’s ambulation status. Resident #5 was admitted to the Facility in 9/2014, with [DIAGNOSES REDACTED]. Review of the annual MDS, with an Assessment Reference Date (ARD) of 8/2/16, indicated that the resident was severely impaired for Cognitive Skills for Daily Decision Making.

Review of the MDS, with an ARD of 8/2/16, indicated that the resident required extensive assistance for ambulation in his/her room and required supervision with ambulation in the corridor. Review of the C.N.A. (Certified Nurses Aide) Care Card, updated on 10/13/16, indicated that the resident was independent for ambulation. Review of the resident care plan, edited on 10/24/16, indicated that the resident was independent for mobility. The surveyor observed Resident #5 on 11/3/16 at 8:15 A.M. The resident was ambulating independently in the hallway. The surveyor observed Resident #5 on 11/3/16 at 12:30 P.M. The resident was ambulating independently in the hallway and stopped to look out of the window at the end of the hallway. The surveyor observed Resident #5 on 11/4/16 at 7:30 A.M. The resident was ambulating independently in the hallway. During an interview, on 11/3/16 at 11 A.M., the Assistant Director of Nursing Services (ADNS) said that the MDS was incorrectly coded for the resident’s ambulation status. During an interview, on 11/8/16 at 4:15 P.M., Nurse #2 said that the annual MDS, with an ARD of 8/2/16, was incorrectly coded for the resident’s ambulation status.

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 interviews the Facility staff failed to develop a comprehensive care plan for 2 residents (#10 and #14) in a total sample of 22 residents.

Findings include:

1. For Resident #10 the Facility staff failed to develop a comprehensive care plan for the care of a cardiac pacemaker. Resident #10 was admitted to the Facility in 5/2016, with [DIAGNOSES REDACTED]. Review of the clinical record indicated that although the resident had a cardiac pacemaker, no further documentation was found or provided, such as specific type, settings, how and when the pacemaker checks were to be done. During an interview with Unit Manager (UM) #2, on 11/8/16 at 11:30 A.M., she said that there was no care plan for the resident’s pacemaker.

2. For Resident #14 the Facility staff failed to develop a comprehensive care plan related to Activities of Daily Living (ADL) for Resident #14. Resident #14 was admitted to the Facility in 12/2015 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/25/16, indicated that the resident scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. Review of the Care Area Assessment (CAA) of 4/25/16, indicated to proceed with a care plan for ADL functional status.

Review of the clinical record indicated that there was no active care plan for ADL functional status. During an interview, on 11/7/16 at 11:30 A.M., Nurse #3 said that there was no care plan in place for ADL functional status.

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 reviews and interviews, the Facility staff failed to provide services in accordance with nursing standards of practice for 4 of 5 applicable residents (#3, #7, #15 and #16), related to insulin administration, out of a total sample of 22 residents.

Findings include:

Review of the Nursing 2014 Drug Handbook indicated the following: As with any insulin therapy, [DIAGNOSES REDACTED] (hardening of tissue) may occur at the injection site and delay absorption. Reduce the risks by rotating the injection site with each injection. 1. For Resident #3, the Facility staff failed to ensure that the insulin injection sites were rotated to reduce the potential risk for damage/ irritation to the tissue, and for better absorption of the insulin.

Resident #3 was admitted to the Facility in 5/2016, with [DIAGNOSES REDACTED]. Review of the 10/2016 Physician Orders, indicated that the resident was to receive the following 4 scheduled insulin injections daily:
-[MEDICATION NAME] (long acting) 48 units subcutaneously (SC) at bedtime
-[MEDICATION NAME](fast acting) 8 units SC at 8 A.M.
-[MEDICATION NAME]18 units SC at 12 P.M.
-[MEDICATION NAME]18 units SC at 5 P.M.

Review of the Medication Administration Records (MAR) for September, October and November 2016 indicated the following:
-September, 2016 MAR [MEDICATION NAME] 8 A. M. dose: no insulin injection site was indicated or the documentation was illegible, for 12 out of 30 days. [MEDICATION NAME] 12 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 11 out of 30 days.
-October, 2016 MAR [MEDICATION NAME] 8 A. M. dose: no insulin injection site was indicated or the documentation was illegible, for 6 out of 31 days. [MEDICATION NAME] 12 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 7 out of 31 days. [MEDICATION NAME] 5 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 6 out of 31 days.
-November, 2016 MAR [MEDICATION NAME] P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 7 out of 7 days.

During an interview with Unit Manager #2, on 11/8/16 at 1:30 P.M., she said that the nurses are supposed to document and rotate insulin injection sites in the MAR. 2. For Resident #16, the Facility staff failed to ensure that the insulin injection sites were rotated to reduce the potential risk for damage/ irritation to the tissue, and for better absorption of the insulin. Resident #16 was admitted to the Facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the 10/2016 Physician Orders, indicated that the resident was to receive the following 4 scheduled insulin injections daily: -[MEDICATION NAME] (long acting) 8 units subcutaneously (SC) at bedtime -[MEDICATION NAME](fast acting) 6 units SC at 8 A.M.-[MEDICATION NAME]6 units SC at 12 P.M. -[MEDICATION NAME]4 units SC at 5 P.M. Review of the MARs for September and October of 2016, indicated the following: -September, 2016 MAR [MEDICATION NAME] 8 A. M. dose: no insulin injection site was indicated or the documentation was illegible, for 17 out of 30 days. [MEDICATION NAME] 12 P.M. dose: no insulin injection site was indicated or documentation was illegible, for 9 out of 30 days. [MEDICATION NAME] 5 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 13 out of 30 days. -October, 2016 MAR [MEDICATION NAME] 8 A.M. dose: no insulin injection site was indicated or the documentation was illegible, for 6 out of 31 days. [MEDICATION NAME] 12 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 9 out of 31 days. [MEDICATION NAME] 5 P.M. dose: no insulin injection site was indicated or the documentation was illegible, for 6 out of 31 days. During an interview with Unit Manager #2, on 11/8/16 at 1:30 P.M., she said that nurses are supposed to document and rotate insulin injection sites in the MAR.

3. For Resident #15 the Facility staff failed ensure that the Humalog (insulin) and [MEDICATION NAME] (insulin) injection sites were rotated. Resident #15 was admitted to the Facility in 7/2016, with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 9/23/16, indicated that the resident had a [DIAGNOSES REDACTED]. Review of the 10/2016 and 11/2016 physician’s orders [REDACTED]. a. Humalog solution 100 unit/ml: 12 Units 3 times per day. Further review of the MAR indicated that the Humalog insulin was administered, but there were no documented insulin injection sites on the MAR, on the following dates and times:
– 10/9/16 at 5:00 P.M.
– 10/10/16 at 8:00 A.M.
– 10/11/16 at 5:00 P.M. (administered in the arm but did not indicate right or left arm).
– 10/12/16 at 5:00 P.M.
– 10/14/16 at 5:00 P.M.
– 10/16/16 at 5:00 P.M.
– 10/18/16 at 5:00 P.M.
– 10/19/16 at 5:00 P.M. (administered in the arm but did not indicate right or left arm).
– 10/2016 at 8:00 A.M. and 5:00 P.M.
– 10/21/16 at 5:00 P.M.
– 10/22/16 at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
– 10/23/16 at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
– 10/25/16 at 5:00 P.M.
– 10/27/16 at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
– 10/28/16 at 8:00 A.M. and 5:00 P.M.
– 10/29/16 at 8:00 A.M. and 5:00 P.M.
– 10/30/16 at 5:00 P.M.
– 10/31/16 at 5:00 P.M.
– 11/5/16 at 5:00 P.M. (administered in the arm but did not indicate right or left arm). b. [MEDICATION NAME] solution 100 unit/ml., 22 units at hour of sleep. Further review of the MAR indicated that the [MEDICATION NAME] was administered at 9:00 P.M., but there were no documented insulin injection sites on the MAR, on the following dates: – 10/28/16. – 11/1/16 – 11/7/16 (administered in the arm but did not indicate right or left arm). During an interview with Unit Manager #2, on 11/8/14 at 10:45 A.M., she said that there is no evidence documented on the MAR that the insulin injection sites were consistently rotated.

4. Resident #7 was admitted to the Facility in 8/2016 with [DIAGNOSES REDACTED]. Review of the clinical record, indicated that the resident received insulin subcutaneously for blood sugar results on a sliding scale, as needed, up to three times a day. Review of the MAR for 10/2016, indicated missing documentation of insulin injection sites for 22 out of 31 days. During an interview, on 11/7/16 at 11:00 A.M., Nurse #3 said that the 10/2016 MAR indicated that there was missing documentation of the insulin injection sites.

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 to follow the plan of care relative to activities, and the physician orders [REDACTED].#1, #8 and #10), in a total sample of 22 residents.

Findings include:

1. For Resident #1, the Facility failed to follow the activity care plan relative to: putting the music channel on the TV when the resident does not attend activities, and providing 1:1 social visits.

Resident #1 was admitted to the facility in 3/2011 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/25/15, indicated that Resident #1 had highly impaired vision and that he/she identified the following activity preferences as very important: listening to music, reading books, newspapers, magazines, being around animals such as pets, keeping up with the news, doing things with groups of people, and going outside when the weather is good. Review of the activity plan of care, initiated on 12/11/15, included the following interventions: invite and encourage the resident to attend and participate in small group activities as tolerated, put on the music channel on the resident’s TV when the resident is not attending activities, and provide 1:1 social visits.

Review of the Activity 1:1 Social Visits document indicated the following:
– week of 5/22/16 through 5/28/16; the resident was provided with 10 minutes of conversation
– weeks of 5/29/16 through 8/30/16; no 1:1 social visits were provided except for:
– week of 7/31/16 through 8/6/16; the resident was provided with 10 minutes of conversation
– week of 8/21/16 through 8/27/16; the resident was provided with 10 minutes of conversation
– week of 8/28/16 through 9/3/16; the resident was provided with 10 minutes of conversation
– week of 9/4/16 through 9/10/16; no 1:1 social visits were provided
– on 9/13/16, was was noted to be on a bed hold – weeks of 9/18/16 through 10/22/16 no 1:1 social visits were provided
-week of 10/23/16 through 10/29/16; the resident was provided with 15 minutes with reading Review of the Activity Progress Note, dated 8/9/16, indicated that Resident #1 continued to be dependent on staff for activities and for cognitive stimulation.

Further review of the note indicated that Resident #1 did not attend many activities, but did listen to music on the TV, attended birthday parties and had 1:1 social visits with staff. The surveyor observed Resident #1 on 11/2/16 at 12:05 P.M. Resident #1 was lying on the bed with the TV was on, but there was no volume. The surveyor observed Resident #1 on 11/3/16 at 8:00 A.M. Resident #1 was lying on the bed with the TV on the news channel. The surveyor observed Resident #1 on 11/8/16 at 9:00 A.M. Resident #1 lying on the bed and the TV was not on. During an interview, on 11/8/16 at 9:15 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #1 is usually in his/her bed during the day. She further said that she puts the TV on for Resident #1 and that he/she does not attend activities. During an interview, on 11/8/16 at 11:15 A.M., the Activities Director (AD) said that Resident #1 receives 1:1 visits by activities staff weekly. During an interview, on 11/8/16 at 11:45 A.M., the AD said that she conducted an in-service with the activity staff to discuss the need to re-approach Resident #1 when he/she is sleeping during the day and throughout the week for 1:1 visits, as they were not completed as care planned.

2. For Resident #8 the Facility staff failed to apply a left wrist splint as ordered by the Physician. Resident #8 was admitted to the Facility in 6/2016, with [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED].M. care and to it remove with P.M. care. Review of the occupational therapy discharge summary, dated 8/10/16, indicated that the resident was tolerating a left wrist extension splint for up to 6 hours. The discharge summary further indicated that staff education regarding splint schedule and precautions was completed. Review of the resident’s care plan for alteration in ability to complete activities of daily living, relative to left wrist drop, indicated the following approach: – The resident is to wear the left wrist splint daily when he/she is out of bed; staff to apply with A.M. care and remove with P.M. care.

During an observation of the resident, on 11/2/16 at 12:35 P.M., the surveyor observed Resident #8 in the hallway, on unit, in a wheelchair, with no left wrist splint applied. During an observation of the resident, on 11/3/16 at 10:20 A.M., the surveyor observed Resident #8 seated in wheel chair, across from the nurses station, with no left wrist splint applied. Review of the September, October and November 2016 General Flowsheets, indicated an entry for the resident to have the left wrist splint applied with A.M. care and removed with P.M. care, however, there was no documentation that this was completed. During interview on 11/3/16 at 12:20 P.M., Unit Manager #2 said that she had not seen a left splint used and was unaware of any splint use with Resident #8. 3. For Resident #10, the Facility staff failed to provide oxygen therapy as ordered by the Physician. Resident #10 was admitted to the Facility in 5/2016 with [DIAGNOSES REDACTED]. Review of the Physicians Orders indicated that on 6/13/16, the Physician wrote an order for [REDACTED].

Review of the July 2016 – November 2016 monthly treatment flowsheets for oxygen use, indicated the resident received oxygen at 2 – 2.5 LPM and not at the 3 LPM, as ordered, with the exception of the following 2 dates and shifts: -9/2/16 on 3:00 P.M.-11:00 P.M. & 11:00 P.M. -7:00 A.M. -9/21/16 on 3:00 P.M.-11:00 P.M. During an observation, on 11/2/16 at 12:25 P.M., the surveyor observed Resident #10 in the unit day/dining room, in a wheelchair, with oxygen applied via NC at 2 LPM. During an observation, on 11/3/16 at 1:25 P.M., with Unit Manager(UM) #2, the surveyor observed Resident #10 in the unit day/dining room, in a wheelchair, with oxygen applied via NC at 2.5 LPM. During an interview with UM #2, on 11/3/16 at 1:30 P.M., she said that the oxygen flow rate was not being provided to the resident at 3 LPM, as ordered, by the Physician.

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

Based on observations, test tray temperatures, interviews and record reviews, the Facility staff failed to ensure that the food was palatable, at proper temperature and delivered timely, for 2 of 4 dining areas.

Findings include:

1. Review of Meal Delivery Time Sheet provided to the surveyor upon entrance to the survey on 11/2/16 at 8:30 A.M., indicate the following times:

a. Breakfast:
Unit 3- 7:40 A.M.
Unit 3- 7:50 A.M.
Unit 4- 8:00 A.M.
Unit 4- 8:10 A.M.
Unit 2- 8:20 A.M.
Unit 2- 8:30 A.M.
Dining Room- 8:30 A.M.

b. Lunch:
Unit 3- 11:40 A.M.
Unit 3- 11:50 A.M.
Unit 4- 12:00 P.M.
Unit 4- 12:10 P.M.
Unit 2- 12:20 P.M.
Unit 2- 12:30 P.M. Dining Room- 12:30 P.M.

c. Dinner:
Unit 3- 4:40 P.M.
Unit 3- 4:50 P.M.
Unit 4- 5:00 P.M.
Unit 4- 5:10 P.M.
Unit 2- 5:20 P.M.
Unit 2- 5:30 P.M.
Dining Room- 5:30 P.M.

2. During a group interview, on 11/2/16 at 2:30 P.M., with the surveyor, 11 residents (who were identified by the Activity Director as alert, oriented and reliable for information), said that the hot foods were cold most of the time and that all meals were served approximately 1 hour later then scheduled.

3. On 11/2/16 at 12:52 P.M., the surveyor observed the food cart arrive on the 4th floor. During an interview, on 11/2/16 at 1:05 P.M., Non-Sampled (NS) Resident #1 said that the lunch is supposed to arrive at 12:15 P.M., but has been 30-40 minutes late every day.

4. On 11/3/16 at 8:17 A.M., the surveyor observed the first food cart arrive on the 4th floor, 17 minutes late. On 11/3/16 at 8:30 A.M., the surveyor observed the second food cart arrive on the 4th floor, 20 minutes late. During an interview, on 11/3/16 at 8:45 A.M., in the 4th floor dining room, NS #2 said that they give the meal and leave ., and no one is in here- I don’t like scrambled eggs and I don’t drink milk. During an interview, on 11/3/16 at 8:45 A.M., in the 4th floor dining area, NS #3 said that the food is dreadful and that it’s all mixed together and he/she said that staff did not say what the food items are when the meal is served.

5. During an observation, on 11/3/16 at 11:30 A.M. through 12:55 P.M., the surveyor observed tray line service for the lunch meal in the kitchen. The surveyor did not observe that food temperatures were taken prior to and throughout the meal service period. The surveyor observed the first tray was plated at 11:55 A.M. At 12:40 P.M., the surveyor observed that disposable knives were used in place of dinnerware for the meal service. At 12:50 P.M., the surveyor observed the test tray was plated and put onto the second cart for the 4th floor. The second food cart left the kitchen at 12:55 P.M. and arrived on the 4th floor at 12:57 P.M

The 1st tray from the cart was served at 1:00 P.M. The surveyor retrieved the test tray, which was the last tray served, at 1:23 P.M. and conducted test tray temperatures as follows: Savory Roasted Chicken- 115.3 degrees Fahrenheit (F), slightly warm to taste; Potatoes Medley- 98.4 degrees F, potatoes were hard, difficult to chew and room temperature to taste; Yellow Squash- 116.3 egress F, warm to taste and noted that food item was not on posted menu for the meal period; disposable knife on meal tray in place of regular dinnerware 6. During an interview, on 11/3/16 at 2:00 P.M., the Ombudsman said that there have been on-going complaints about the food for the past 2 years.

7. During an interview, on 11/8/16 at 11:20 A.M., with a family member of NS #4, he/she said that the food is never on time and that he/she comes in everyday for lunch to make sure that NS #4 is served the noon meal. The family member further said that the meals do not arrive until 1:00-1:30 P.M. in the Main Dining Room (MDR), which is located on the first floor, and that although NS #4 goes for socialization, he/she is considering having NS #4 eat on the unit because the meal service is so late, and there is a concern regarding medication that NS #4 has to take prior to the meals.

7. Review of the Food Temperature Chart for 10/1/16 through 11/8/16, indicated that the temperatures were not conducted on the following dates/times:
10/2/16- dinner
10/3/16- lunch, dinner
10/4/16 through 10/11/16- breakfast, lunch, dinner
10/12/16- breakfast, lunch
10/13/16- dinner
10/14/16 through 10/15/16- breakfast, lunch, dinner
10/16/16- breakfast, lunch
10/17/16- dinner 10/18/16 through 10/20/16- breakfast, lunch, dinner
10/21/16-dinner
10/22/16 through 10/23/16- breakfast, lunch, dinner
10/24/16- dinner 10/25/16- breakfast, lunch, dinner
10/26/16- breakfast, lunch
10/27/16 through 11/1/16- breakfast, lunch dinner
11/2/16- dinner 11/3/16 through 11/6/16- breakfast, lunch, dinner
11/7/16- lunch

During in interview, on 11/8/16 at 1:45 P.M., the Food Service Director (FSD) reviewed the temperature logs with the surveyor, and said that the temperatures of the foods were not consistently taken prior to meal service to ensure that they were within the desirable range prior to service. The FSD said that the dietary staff do not pass the resident meal trays.

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

Based on observations, interviews and policy review, the Facility staff failed to ensure that the food was served under sanitary conditions and that kitchen surfaces remained clean and free of debris.

Findings include:

During the kitchen tours on 11/2/16 at 8:30 A.M., 11/3/16 at 11:30 A.M. and 11/8/16 at 1:45 P.M (with the Food Service Director), the surveyor observed the following:

1. The walk in refrigerator contained:
a. 2 full size pans with wrapped hamburger (5 pound (lb) bricks) – 13 of them with no label/no date
b. 5 lb bag of mozzarella cheese with no label/no date
c. 5 lb bag of opened parmesan cheese with no label/no date
d. 8 lb brick of opened Swiss cheese with no label/no date 2. The walk in freezer contained multiple red colored drippings on the wall that extended onto the freezer floor measuring approximately 2 feet in length.

3. The kitchen floor was observed with food debris throughout, and black built up residue was observed in the corners and under the kitchen equipment.

4. Several, small winged insects were observed flying around the juice machine and by the employee hand washing sink.

5. The stove was observed with black built up residue on the back splash, as well as the surrounding the burners.

6. The shelf under the steam table was observed with dust, crumbs, and white and brown food residue on the surface. The shelf also contained several different sized bowls on purple mats that had various colors of dried food particles.

7. A plunger was observed on the floor, under the 3 compartment sink.

8. A rack that was located near the reach in refrigerator, that contained clean pots and pans, was observed to have shelves that were sticky and tacky to the touch, and had numerous dried food drippings.

9. On 11/3/16 at 11:45 A.M. and 11:52 A.M., the surveyor observed Dietary Aide #1, cutting up lettuce and tomatoes with no beard restraint on. At 12:10 P.M., the surveyor observed Dietary Aide #1, drinking from a large pitcher containing a red liquid at the same preparation table that he was cutting vegetables. The surveyor observed Dietary Aide #1 put the pitcher of red beverage onto the shelf under the preparation table, and continue to work without washing his hands.

10. On 11/8/16 at 1:45 P.M., the surveyor observed Dietary Aide #1, cutting up fresh squash at the preparation table with no beard restraint on.

Review of the Personal Hygiene Policy (revised on 2/1/14), indicate the following: – Beards or any body hair that may be exposed (i.e. arms) must be covered – Eating and drinking are not permitted in food preparation and service areas During an interview, on 11/8/16 at 1:45 P.M., the Food Service Director (FSD) said that hair restraints and beard nets (if applicable) must be worn by anyone who enters the kitchen. The FSD further said that there was no cleaning schedule utilized at this time to ensure that the cleanliness/sanitation of the kitchen were maintained.

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 staff interview, the Facility staff failed to ensure that separately locked, permanently affixed compartments for storage of controlled drugs were available on 3 of 3 units, and the Facility staff failed to ensure that medications and biologicals were of current date on 3 out of 3 units.

Findings include:

1a. Unit 2: During an inspection, of the Unit 2 medication room, on [DATE] at 1:00 P.M., the medication refrigerator was observed to be unlocked and contained 2 boxes of Ativan (a controlled, antianxiety medication) on a shelf and were for 2 specific residents. During an interview, on [DATE] at 1:10 P.M., the Assistant Director of Nursing Services (ADNS) said she had just been in the medication room and she had unlocked the refrigerator. The ADNS said that there was no separately locked, permanently affixed compartment for the Ativan medication in the refrigerator.

1b. Unit 3: During an inspection, of the Unit 3 medication room, on [DATE] at 3:00 P.M., the locked medication refrigerator was observed to contain a blister card with 10 tablets of Marinol (a controlled medication to decrease symptoms of nausea and vomiting), for 1 specific resident. The blister card was observed on a shelf in the refrigerator. During an interview, on [DATE] at 3:10 P.M., UM #2 said that there was no separately locked, permanently affixed compartment for the Marinol in the refrigerator.

1c. Unit 4: During an inspection, of the Unit 4 medication room, on [DATE] at 3:30 P.M., it was observed that there was no separately locked, permanently affixed compartment for storage of controlled drugs in the medication refrigerator. During an interview, on [DATE] at 3:40 P.M., Nurse #1 said that there was no separately locked, permanently affixed, compartment in the refrigerator for storage of controlled drugs.

2a. Unit 2: During an inspection, of the Unit 2 medication room, on [DATE] at 1:20 P.M., 1 box of Hemoccult slides (a method used to detect presence of blood in the stool), was observed with an expiration date of ,[DATE]. During an interview, on [DATE] at 1:25 P.M., the ADNS said that the Hemoccult slides were expired and she discarded them.

2b. Unit 3: During an inspection, of the Unit 3 medication room, on [DATE] at 3:15 P.M., 2 bottles of Multivitamins were found with an expiration date of ,[DATE] listed on each bottle. During an interview, on [DATE] at 3:20 P.M., UM #2 said that the 2 bottles of Multivitamins were expired and she discarded them.

2c. Unit 4: During an inspection, of the Unit 4 refrigerator in the medication room, on [DATE] at 3:45 P.M., an opened vial of Tuberculin Purified Protein Derivative (PPD), (a skin test used to determine whether a person is infected with [DIAGNOSES REDACTED]), was observed with no documentation of the date that the vial was opened or expiration date listed. During an interview, on [DATE] at 3:50 P.M., Nurse #1 said there was no documentation indicating when the vial was opened and no expiration date listed on the opened bottle of PPD.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility staff failed to provide isolation precautions when indicated, to prevent the spread of infection, for 1 resident (# 3) with an infection, out of a total sample of 22 residents.

Findings include:

Resident #3 was admitted to the Facility in 5/2016, with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment, dated 11/3/16, indicated that the resident required extensive assistance with toileting, and was frequently incontinent of both bowel and bladder. Resident #3 resided in a semi private room and had a roommate. Review of the laboratory report dated 11/3/16, indicated that Resident #3’s urine was positive for the following organisms: [DIAGNOSES REDACTED] Pneumonia and a drug resistant organism Escherichia Coli (ESBL). During an observation, on 11/4/16 at 12:00 P.M., Resident #3 was seated, in a wheel chair, eating lunch in his/her room.

During an interview, on 11/8/16 at 1:05 P.M., Unit Manager (UM) #2, said that she was unaware that Resident #3 had a UTI with ESBL (a drug resistant bacteria). She said Resident #3 is on standard precautions, which are in place for all residents. UM #2 said that Resident #3 should have been placed on contact precautions, and should not share bathroom facilities. She further said that both the resident and the resident’s roommate currently share the same bathroom. During an interview, on 11/8/16 at 1:40 P.M., the Facility Infection Control Nurse said that according to the Facility infection control practices and the Facility policy, Resident #3 should have been placed on contact precautions to prevent the spread of infection. A sign should be outside the resident’s room to alert staff and visitors to speak to the nurse prior to entering the room. She further stated that Resident #3 should not be sharing a bathroom (toilet). During an interview, on 1/8/16 at 2:00 P.M., Certified Nursing Assistant #1 said that both Resident #3 and non-sampled (NS) Resident #5 are roommates and both use the same bathroom.

1) Failed to receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation

Based on review of personnel files and staff interview, the Facility staff failed to verify that 1 of 2 newly hired Certified Nursing Assistants (Employee # 3) met competency evaluation requirements, and to obtain proof that the employee had successfully completed a training and competency evaluation program.

Findings include:

Employee #3 was hired on 9/13/16, as a Certified Nursing Aide (CNA). Review of the personnel file indicated that the Nurse Aide Registry check, was completed on 10/17/16, and not prior to employment, as required. During an interview, with the Administrator and the Human Resource Specialist, on 11/3/16 at 2:50 P.M., they said that the Nurse Aide Registry check should have been completed prior to the date of hire.

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 interviews and record reviews, the Facility staff failed to maintain an accurate and complete clinical record relative to circumstances surrounding a transfer and readmission to an acute care facility for 1 sampled resident (#17), in a total sample of 22 residents.

Findings include:

Resident #17 was admitted to the Facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the Nurses Notes, dated 11/10/15, indicated that Resident #17 experienced a witnessed fall in the bathroom at 7:10 A.M., resulting in a large bump/possible hematoma on his/her forehead, and was transferred out to the emergency for further evaluation. Further review of the Nurses Notes indicated that the next entry by nursing staff was dated on 11/12/15.

During an interview, on 11/8/16 at 10:20 A.M., the Assistant Director of Nurses Services(ADNS) said that Resident #17 was readmitted to the facility on the same day of transfer out the emergency roiagnom on [DATE]. She further said that there was no documentation in the clinical record indicating this information.

Wingate at Springfield Rehabilitation and Skilled Nursing, 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 Profile for Wingate at Springfield Rehabilitation and Skilled Nursing

Safety, Health and Inspection Report for Wingate at Springfield Rehabilitation and Skilled Nursing 11/08/2016

Page Last Updated: February 5th, 2017

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