Inspection Reports for
Blaire House of Tewksbury
10 Erlin Terrace, Tewksbury, MA 01876, Tewksbury, MA, 01876
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 29, 2025
Visit Reason
The investigation was conducted due to a complaint regarding Resident #1 leaving the facility without proper supervision or following the required protocol for social leaves of absence.
Complaint Details
The complaint investigation was substantiated. Resident #1, who had a Court Ordered Legal Guardianship and required accompaniment on social leaves, left the facility without proper supervision or following protocol. The facility notified the Guardian and police, and Resident #1 was found intoxicated in a hospital emergency department.
Findings
The facility failed to ensure staff consistently implemented the care plan interventions requiring identification and contact information of persons accompanying Resident #1 on social leaves. Resident #1 eloped from the facility unsupervised and was later found intoxicated in a local hospital emergency department.
Deficiencies (2)
F 0656: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to obtain identification information of the person taking Resident #1 out on a social leave as required by the care plan.
F 0689: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to provide adequate supervision to prevent Resident #1 from eloping undetected and leaving the facility unaccompanied.
Report Facts
Residents Affected: 1
BIMS score: 14
Date of incident: Dec 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Mentioned in relation to failure to obtain identification information and awareness of Resident #1's absence | |
| Nurse #2 | Reported Resident #1 missing and checked sign-out book; notified staff and authorities | |
| Director of Nursing | Director of Nursing | Provided information on staff awareness and investigation findings |
| Director of Social Services | Director of Social Services | Provided information on staff education and Resident #1's plan of care |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 23, 2024
Visit Reason
Routine inspection of Blaire House of Tewksbury nursing home to assess compliance with regulatory standards including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, incomplete informed consent for psychotropic medication, lack of advance directives documentation, neglect in incontinence care, improper use of restraints, inaccurate Minimum Data Set assessments, incomplete care plans, inadequate assistance with activities of daily living, fall prevention failures, improper catheter care, PICC line maintenance issues, trauma-informed care deficiencies, behavioral health care gaps, and food temperature and palatability concerns.
Deficiencies (16)
F 0550: The facility failed to provide a dignified dining experience by not serving all residents at the same table at the same time.
F 0552: The facility failed to obtain psychotropic medication consent prior to administration for one resident.
F 0578: The facility failed to ensure advance directives were consistently documented in the medical record for one resident.
F 0600: The facility failed to prevent abuse by neglecting to provide timely incontinence care for one resident.
F 0604: The facility failed to keep one resident free from physical restraints by positioning the bed against the wall without a restraint assessment.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments by incorrectly documenting a resident's discharge status.
F 0656: The facility failed to develop comprehensive care plans for residents with pacemakers and opioid dependence histories.
F 0677: The facility failed to provide timely incontinence care, supervision during eating, and showers for multiple residents.
F 0688: The facility failed to ensure a resident wore a prescribed left-hand splint to prevent contracture.
F 0689: The facility failed to implement fall prevention interventions including use of alarms and fall mats for multiple residents.
F 0690: The facility failed to obtain physician orders for Foley catheter placement and changes, including catheter and balloon size, for one resident.
F 0694: The facility failed to obtain baseline and ongoing measurements of a resident's PICC line external length and failed to date PICC dressings.
F 0699: The facility failed to develop personalized trauma-informed care plans for residents with PTSD.
F 0740: The facility failed to provide necessary behavioral health care and services including following psychiatric medication recommendations and completing psychiatric consults.
F 0804: The facility failed to serve food and drink at safe and appetizing temperatures, with many items served lukewarm or cold.
F 0842: The facility failed to maintain accurate medical records by marking orders as complete when splint use and bed alarm use were not implemented.
Report Facts
PICC line dressing change frequency: 1
Psychotropic medication doses used: 15
Fall dates: 5
Fall dates: 4
Fall dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Noted absence of psychiatric notes for Resident #105 and lack of psychiatric consult completion |
| Unit Manager #1 | Unit Manager | Interviewed regarding dining service, behavioral health recommendations, and splint use |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including fall prevention, psychiatric consults, and care plan deficiencies |
| Nurse #3 | Nurse | Changed Foley catheter without physician order for Resident #50 |
| Certified Nursing Assistant #1 | CNA | Reported on toileting and feeding assistance for multiple residents |
| Certified Nursing Assistant #2 | CNA | Reported on incontinence care delays for residents |
| Certified Nursing Assistant #3 | CNA | Reported on feeding assistance for Resident #95 |
| Certified Nursing Assistant #4 | CNA | Unaware of splint order for Resident #54 |
| Certified Nursing Assistant #5 | CNA | Reported on incontinence care delays for Resident #83 |
| Social Worker | Social Worker | Reviewed PTSD care plans and noted lack of personalization |
| Nurse #5 | Nurse | Observed missing bed alarm for Resident #3 |
| Nurse #7 | Nurse | Unaware of fall mat intervention for Resident #43 |
| Food Services Director | Food Services Director | Reported on food temperature standards |
Inspection Report
Routine
Census: 27
Deficiencies: 23
Date: Oct 17, 2023
Visit Reason
Routine inspection of Blaire House of Tewksbury nursing home to assess compliance with regulatory requirements including resident care, infection control, nutrition, medication management, and safety.
Findings
The facility had multiple deficiencies including undignified treatment of residents during meals, failure to notify physicians of significant weight loss, breaches of resident confidentiality, failure to file grievances, use of physical restraints without orders, failure to investigate abuse allegations, failure to provide required transfer/discharge notices, incomplete care plans, inadequate assistance with activities of daily living, failure to implement physician orders for pressure ulcer care, failure to provide therapeutic diets as ordered, unsafe food handling practices, incomplete medication record keeping, unlocked medication carts, lack of a qualified dietician, and improper infection control during a COVID-19 outbreak.
Deficiencies (23)
F 0550: Staff referred to residents as feeders and failed to serve all residents at the same time during meals, fed residents while standing over them, and served residents on overbed tables.
F 0580: Facility failed to notify the physician of significant weight loss for Resident #90, who lost 29.07% body weight in 30 days.
F 0583: Facility failed to protect resident confidentiality when Physician #1 loudly dictated resident notes at nurses station and left computer screens with PHI visible.
F 0585: Facility failed to file a grievance for Resident #90's missing left hearing aid, resulting in unresolved loss of personal property.
F 0604: Resident #63 was physically restrained by placement of fall mats and wheelchair blocking exit without physician order or care plan.
F 0607: Facility failed to investigate an allegation of rough handling causing a bruise on Resident #80's wrist.
F 0609: Facility failed to timely report and investigate an allegation of sexual abuse involving Resident #32.
F 0623: Facility failed to provide required transfer/discharge notices to Residents #2 and #22 or their representatives.
F 0625: Facility failed to provide required bedhold notices to Residents #2 and #22 or their representatives.
F 0656: Facility failed to develop and implement care plans for Residents #87, #90, and #31 related to gastrostomy tube sponge orders, skin breakdown, and pressure ulcer prevention.
F 0677: Facility failed to provide scheduled showers to Resident #62 and failed to provide feeding assistance to Resident #63 despite documented need.
F 0686: Facility failed to implement physician orders for Resident #90 to wear a soft protective boot, increasing risk for skin breakdown.
F 0688: Resident #13 did not wear right-hand splint properly or as ordered by physician.
F 0692: Facility failed to monitor weights as required for Resident #87 and failed to implement nutritional care plan for Resident #90, resulting in unaddressed significant weight loss.
F 0695: Facility failed to replace and date oxygen tubing weekly for Resident #55 as ordered.
F 0756: Facility failed to submit pharmacist medication recommendations to physician for Resident #3 and failed to maintain documentation of physician response.
F 0761: Medication cart was found unlocked and unattended on 2 [NAME] unit.
F 0801: Facility lacked a qualified dietician since May 2023, resulting in failure to assess nutritional needs of residents including Resident #37.
F 0804: Facility failed to ensure foods were served at safe temperatures and handled with proper hygiene, including serving undercooked eggs and feeding residents with bare hands.
F 0808: Resident #37 was provided nectar thick liquids instead of honey thick as ordered, increasing risk for aspiration.
F 0810: Resident #37 was not provided a nosey cup as ordered, increasing risk for aspiration.
F 0842: Resident #90's Treatment Administration Record inaccurately documented use of protective boots not worn; Resident #31's TAR and skin assessments were inaccurate; pharmacy consultation report missing for Resident #3.
F 0880: Facility failed to enforce proper PPE use during COVID-19 outbreak; staff and physician wore masks improperly increasing risk of transmission.
Report Facts
Residents affected: 10
Weight loss percentage: 29.07
Weight loss percentage: 8.72
Temperature: 87
Temperature: 98
Temperature: 105
Temperature: 113
Temperature: 114
Temperature: 117
Temperature: 123
Temperature: 131
Temperature: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Dictated resident notes loudly during COVID-19 outbreak without mask covering mouth and nose | |
| Unit Manager #1 | Observed not wearing N95 mask properly during COVID-19 outbreak | |
| Nurse #3 | Returned to unlocked medication cart | |
| Director of Nursing | Director of Nursing | Multiple interviews regarding weight loss, infection control, medication management, and other deficiencies |
| Unit Manager #2 | Unable to locate pharmacist consultation report | |
| Food Service Director | Food Service Director | Interviewed about food temperatures and dietary orders |
| Nurse Practitioner #2 | Nurse Practitioner | Interviewed about weight loss notification and management |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about Resident #90's boot use |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about Resident #31's skin and feeding assistance |
| Nurse #7 | Nurse | Interviewed about Resident #31's skin and heel protectors |
| Unit Manager #1 | Interviewed about feeding assistance and splint use | |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about splint placement |
Inspection Report
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with policies and procedures related to abuse prevention, specifically focusing on employee background checks for Certified Nurse Aides.
Findings
The facility failed to implement its policy and ensure that a Massachusetts Nurse Aide Registry background check was conducted before hiring a Certified Nurse Aide, as required by facility policy and staffing agency agreement.
Deficiencies (1)
F 0607: The facility did not conduct or document a Massachusetts Nurse Aide Registry background check prior to hiring Certified Nurse Aide #1 on 05/18/23, violating abuse prevention policies.
Report Facts
Residents Affected: 3
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Sep 1, 2022
Visit Reason
The inspection was conducted based on complaint investigations related to alleged violations including failure to investigate bruises of unknown origin, failure to develop and implement behavioral care plans, failure to revise care plans, inadequate pressure ulcer care, inadequate supervision to prevent falls, improper respiratory care, failure to provide necessary behavioral health care, improper food storage and disposal, inaccurate medical records, and infection prevention deficiencies.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to investigate bruises, inadequate care planning for behavioral issues, pressure ulcer prevention failures, falls prevention, respiratory care, behavioral health services, food safety, medical record accuracy, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to investigate bruises, incomplete behavioral care plans for residents with sexually inappropriate behaviors, failure to revise care plans after incidents, inadequate pressure ulcer prevention, insufficient supervision to prevent falls, improper respiratory equipment handling, failure to provide recommended psychotherapy, expired food storage, inaccurate oxygen administration records, and improper disinfection of shared blood glucose meters.
Deficiencies (10)
F 0610: The facility failed to investigate bruises of unknown origin for one Resident (#72) out of 22 sampled residents.
F 0656: The facility failed to develop and implement a behavioral care plan addressing sexually inappropriate behaviors for one Resident (#88) out of 22 sampled residents.
F 0657: The facility failed to revise care plans for two Residents (#23 and #78) after incidents of self-harm and sexually inappropriate behavior.
F 0686: The facility failed to ensure pressure relieving devices were in place per physician orders for one Resident (#77) at risk for pressure ulcers.
F 0689: The facility failed to provide adequate supervision and revise a falls care plan to prevent falls for one Resident (#88) out of 22 sampled residents.
F 0695: The facility failed to provide safe and appropriate respiratory care related to replacing, dating, and storing oxygen and nebulizer tubing for three Residents (#3, #50, #513).
F 0740: The facility failed to implement behavioral services (individualized psychotherapy) as recommended for one Resident (#23) out of 22 sampled residents.
F 0812: The facility failed to dispose of expired foods in the kitchen and in 3 of 3 nursing unit nourishment kitchens.
F 0842: The facility failed to maintain an accurate medical record related to oxygen administration for one Resident (#50).
F 0880: The facility failed to ensure proper disinfection of a shared blood glucose meter, placing residents at risk for bloodborne diseases.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Expired food items: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Observed failing to disinfect blood glucose meter properly | |
| Social Worker #1 | Social Worker | Interviewed regarding behavioral care plan and suicide risk assessment |
| Psychiatric Nurse Practitioner (NP #1) | Psychiatric Nurse Practitioner | Interviewed regarding psychotherapy services for Resident #23 |
| Director of Nursing | Director of Nursing | Interviewed regarding bruising investigation and pressure ulcer care |
| Staff Development Coordinator | Interviewed regarding pressure ulcer care and oxygen administration | |
| Food Service Director | Food Service Director | Interviewed regarding expired food items |
| Unit Manager | Interviewed regarding behavioral health allegations |
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