Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: Feb 5, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, inadequate assistance with call bell and mobility equipment, incomplete care plans, failure to follow physician orders, improper medication storage and administration, poor infection control practices including failure to implement enhanced barrier and droplet precautions, inadequate food safety and sanitation, improper waste disposal, and incomplete staff performance reviews.
Deficiencies (13)
Staff stood over residents while assisting with meals and referred to residents as feeders, violating dignity policies.
Resident #15's call bell did not function properly and Resident #44's Broda chair was unavailable when needed.
Failed to develop a skin impairment care plan for Resident #33 despite presence of a wound.
Failed to review and revise care plan related to air mattress use for Resident #69; air mattress settings were not included in care plan.
Failed to implement physician orders for Residents #28, #101, and #69 including use of ace wraps, abdominal binder, prevalon boots, and arm elevation.
Resident #25 and #55 were not provided necessary assistance and supervision during meals as required by their care plans.
Residents #60 and #33 were not provided timely incontinence care as required by care plans and assessments.
Resident #75 had blood pressure readings taken on the arm with a dialysis fistula contrary to physician orders and facility policy.
Medications for Residents #15 and #18 were left unsecured in resident rooms; medication carts were left unattended and unlocked; medication keys were left unattended; medication was left at bedside without ensuring administration.
Food items in the kitchen were not properly dated or labeled; food was stored with chemicals; food storage areas were unclean; and food safety policies were not followed.
Garbage and trash were not properly contained around dumpsters, creating risk for pests.
Medical records for Residents #28, #101, and #33 were inaccurate, including documentation of physician orders and skin assessments.
Infection prevention and control program deficiencies included failure to maintain hand hygiene and glove use during wound care for Residents #89 and #33, failure to implement enhanced barrier precautions for Residents #84 and #15, failure to post isolation/droplet precaution signage for Resident #217, and failure to follow droplet precautions for residents with influenza on multiple units.
Report Facts
Resident sample size: 31
Blood pressure readings on fistula arm: 34
Blood pressure readings on fistula arm: 4
Weekly skin assessments completed: 5
Weekly skin assessments opportunities: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Unaware of physician orders for Residents #28 and #101; admitted to marking orders as completed when not done | |
| Nurse #2 | Observed with wound care and medication storage issues; stated treatments should not be left in resident rooms | |
| Nurse #4 | Observed performing wound care without proper hand hygiene between glove changes; acknowledged errors | |
| Nurse #5 | Observed leaving medication cart open | |
| Nurse #7 | Observed leaving medication cart unlocked with keys on top; acknowledged policy violations | |
| CNA #1 | Certified Nursing Assistant | Provided incontinence care for Resident #60; admitted to not checking resident frequently enough |
| CNA #2 | Certified Nursing Assistant | Provided morning care for Resident #33; admitted to not checking resident frequently enough |
| CNA #3 | Certified Nursing Assistant | Observed not wearing full PPE for resident on droplet precautions |
| CNA #5 | Certified Nursing Assistant | Stated supervision is required for Resident #55 during meals |
| CNA #6 | Certified Nursing Assistant | Stated Resident #25 requires staff to feed and supervise during meals |
| Director of Nursing | Director of Nursing | Multiple interviews acknowledging deficiencies and expectations for compliance |
| Human Resource Director | Human Resource Director | Unable to explain missing annual CNA performance reviews |
| Food Service Director | Food Service Director | Observed food safety violations and trash issues; acknowledged problems |
| Regional Food Service Director | Regional Food Service Director | Observed food safety violations and trash issues; acknowledged problems |
| Maintenance Director | Maintenance Director | Acknowledged trash containment issues outside facility |
| Regional Maintenance Director | Regional Maintenance Director | Acknowledged trash containment issues outside facility |
| Unit Manager #2 | Unit Manager | Acknowledged deficiencies in wound care, air mattress care plan, medication administration, and infection control |
| Charge Nurse #3 | Charge Nurse | Acknowledged need for droplet precaution signage and PPE use |
| Nurse #3 | Observed dignity issues during meals and inappropriate use of term 'feeder' |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving Resident #1, specifically related to the administration and reconciliation of Eliquis dosage upon admission.
Complaint Details
The investigation was complaint-driven, focusing on a medication error involving Resident #1. The complaint was substantiated as the facility failed to act on a time-sensitive pharmacy recommendation dated 04/15/24. Resident #1 was overmedicated with Eliquis, leading to serious health consequences and hospitalization.
Findings
The facility failed to ensure timely nursing review and action on a time-sensitive pharmacy recommendation to adjust Resident #1's Eliquis dosage, resulting in overmedication for more than a month. Resident #1 experienced acute medical complications including critically low hemoglobin and hematocrit levels, requiring hospital transfer, blood transfusions, and additional treatments. Multiple interviews and record reviews confirmed the medication reconciliation error and lack of follow-up on pharmacy recommendations.
Deficiencies (3)
Failure to ensure timely nursing review and action on pharmacy recommendations regarding Eliquis dosage, leading to overmedication and harm to Resident #1.
Medication reconciliation error upon admission causing Resident #1 to continue receiving an incorrect Eliquis dose.
Failure to ensure residents are free from significant medication errors, resulting in Resident #1's acute medical deterioration.
Report Facts
Dosage of Eliquis administered: 20
Hemoglobin levels: 6.4
Hematocrit levels: 19.2
Date of pharmacy recommendation: Apr 15, 2024
Date of hospital transfer: May 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Unit Manager | Named in relation to missed pharmacy recommendations and medication reconciliation oversight. |
| Consultant Pharmacy Manager | Consultant Pharmacy Manager | Provided information about pharmacy recommendations and lack of follow-up. |
| Nurse Practitioner (NP) | Nurse Practitioner | Unaware of pharmacy recommendation and medication error. |
| Former Director of Nurses (DON) | Director of Nurses | Unaware of missed pharmacy recommendation until notified in June 2024. |
| Interim Director of Nurses (DON) | Interim Director of Nurses | Acknowledged facility expectations for medication reconciliation and follow-up. |
| Assistant Director of Nurses (ADON) | Assistant Director of Nurses | Completed medication reconciliation form and unaware of the medication error until June 2024. |
| Charge Nurse | Charge Nurse | Responsible for informing practitioners of alert order progress notes. |
Inspection Report
Routine
Deficiencies: 15
Date: Feb 9, 2024
Visit Reason
The inspection was a routine regulatory survey of St Joseph Rehab & Nursing Care Center to assess compliance with healthcare facility regulations.
Findings
The facility was found deficient in multiple areas including resident rights and informed consent, environmental safety and cleanliness, care planning, activities of daily living assistance, medication administration, behavioral health services, respiratory care, dialysis care, and infection control. Several residents had unmet needs related to care plans, medication management, and safety precautions.
Deficiencies (15)
Failed to allow Resident #36 to participate in treatment decisions and failed to obtain informed consent for psychotropic medications for Resident #19.
Failed to maintain a safe, clean, and homelike environment with multiple maintenance issues and unclean conditions in resident rooms and common areas.
Failed to develop care plans addressing suicidal and homicidal ideation for Resident #36 and fluid overload/fluid restriction for Resident #86.
Failed to revise care plans for skin impairment for Resident #77 and dialysis access site for Resident #86.
Failed to provide necessary assistance with activities of daily living including meal assistance for Residents #9, #92, #66 and nail care for Resident #413.
Failed to provide an activities program to meet the needs of Resident #9.
Failed to obtain a physician order for wound dressing for Resident #104 and failed to follow physician orders for safe positioning during meals for Resident #20.
Failed to maintain a safe environment by not implementing fall mats for Residents #103 and #43, not providing a wander guard for Resident #36, and not providing padded bed siderails for Resident #8.
Failed to ensure tube feeding was administered at the correct rate for Resident #91.
Failed to provide respiratory care in accordance with physician orders for Residents #88 and #86, including oxygen management and tubing hygiene.
Failed to maintain accurate medical records for Residents #8 and #91, including documentation of padded bed rails and correct tube feeding orders and medication administration routes.
Failed to provide necessary behavioral health care and services for Residents #36 and #96, including non-pharmacological interventions and counseling.
Failed to ensure medication error rates were below 5%, with errors observed in medication administration for Residents #9 and #59.
Failed to ensure medication carts were locked when unattended, kept clean, and medications properly labeled and stored.
Failed to assess for eligibility and offer pneumococcal vaccinations per CDC recommendations for Residents #20, #58, and #71.
Report Facts
Medication error rate: 11.54
Fluid intake: 1140
Fluid intake: 2080
Fluid intake: 1200
Phosphate binder administration delay: 121
Phosphate binder administration delay: 91
Phosphate binder administration delay: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Nurse | Administered medication to Resident #9 without meal; acknowledged error. |
| Nurse #4 | Nurse | Failed to administer eye drops and documented medication as given in error for Resident #59. |
| Unit Manager #1 | Unit Manager | Acknowledged missing floor mats for Resident #103 and incorrect tube feeding orders for Resident #91. |
| Director of Nursing | Director of Nursing | Provided multiple clarifications on care standards and acknowledged deficiencies. |
| Certified Nursing Assistant (CNA) #3 | CNA | Observed oxygen tubing on floor and reapplied it to Resident #88. |
| Certified Nursing Assistant (CNA) #4 | CNA | Observed oxygen tubing on floor and discussed proper replacement. |
| Social Worker #1 | Social Worker | Discussed behavioral health service gaps and responsibilities. |
| Social Worker #2 | Social Worker | Main social worker for Resident #36's floor; unaware of recent behavioral health services. |
| Dietitian | Dietitian | Discussed fluid restriction and tube feeding orders for Resident #86. |
| Unit Manager #3 | Unit Manager | Discussed medication cart cleanliness and pharmacist recommendations. |
| Nurse #6 | Nurse | Discussed muscle rub storage and medication cart cleanliness. |
Inspection Report
Routine
Census: 39
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess the safety and operational status of essential equipment, specifically the automated external defibrillator (AED) and its supplies, on one of the nursing units.
Findings
The facility failed to ensure that all four sets of AED pads stocked and stored with the AED on the fourth floor nursing unit were not expired. Interviews with nursing staff and the Director of Nurses confirmed that expired AED pads were present and should not be used, and that expired equipment should be replaced immediately.
Deficiencies (1)
All four sets of AED pads stocked and stored with the AED were found to be expired.
Report Facts
Residents census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Nurse | Accompanied surveyor during AED inspection and confirmed expired AED pads |
| Nurse #4 | Nurse | Confirmed expired AED pads during interview |
| Director of Nurses | Director of Nurses | Provided information on code cart checks and expectations for replacing expired equipment |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper medication reconciliation and administration for Resident #1, who required anticonvulsant medication for seizure management.
Complaint Details
The complaint investigation focused on Resident #1's medication reconciliation and administration errors, substantiated by findings that the resident went nine days without prescribed anticonvulsant medication, resulting in seizure activity and hospitalization.
Findings
The facility failed to properly review and reconcile Resident #1's medications upon admission, resulting in the resident going nine days without anticonvulsant medication, experiencing seizure activity, and requiring emergent hospital transfer. Additionally, the facility failed to complete admission chart audits and medication reconciliation forms for Resident #1 and two other new admissions, compromising medical record accuracy and resident safety.
Deficiencies (3)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in Resident #1 going nine days without anticonvulsant medication and experiencing seizures.
Failure to ensure residents are free from significant medication errors due to inaccurate medication reconciliation, leading to Resident #1 missing anticonvulsant medication for nine days.
Failure to safeguard resident-identifiable information and maintain complete medical records related to admission chart audits for three sampled residents.
Report Facts
Days without anticonvulsant medication: 9
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Second Floor Unit Manager | Interviewed regarding admission chart audit completion and nursing responsibilities. | |
| Admission Nurse | Interviewed about reviewing admission chart audits for new admissions. | |
| Minimum Data Set (MDS) Nurse | Interviewed about reviewing hospital paperwork and medication reconciliation. | |
| Assistant Director of Nursing (ADON) | Interviewed about facility admission process, chart audits, and medication reconciliation. | |
| Nursing Supervisor | Interviewed about medication review and admission procedures; no longer employed at facility. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, wound care, respiratory care, and other nursing home standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to administer prophylactic antibiotics prior to dental work, failure to provide routine vision services, failure to properly replace and date oxygen tubing, improper medication administration by crushing a do-not-crush medication, incomplete wound care orders, incomplete medication records, and inadequate documentation and monitoring of air mattress settings.
Deficiencies (8)
Failed to maintain dignity for Resident #19 by not storing urinary drainage bag in a privacy bag.
Failed to administer prophylactic antibiotic prior to dental work for Resident #70.
Failed to provide routine vision services for Resident #11.
Failed to replace and date oxygen tubing for Resident #48 as per policy.
Nurse #1 crushed and administered a do not crush medication (divalproex delayed release) to Resident #88.
Incomplete wound care order for Resident #7 lacking wound location, cleansing method, and covering type.
Incomplete medication record for aspirin administration for Resident #15 missing dose information.
Failed to accurately document and monitor air mattress settings for Residents #15, #18, and #359.
Report Facts
Residents sampled: 22
Medication administration observation date: Dec 23, 2022
Weight of Resident #15: 190
Air mattress setting for Resident #15: 170
Weight of Resident #18: 190
Air mattress setting for Resident #18: 140
Weight of Resident #359: 199
Air mattress setting for Resident #359: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Crushed and administered do not crush medication to Resident #88 | |
| Unit Manager #1 | Interviewed regarding urinary catheter privacy bag and air mattress documentation | |
| Unit Manager #2 | Interviewed regarding prophylactic antibiotic administration and medication crushing | |
| Nurse #2 | Interviewed regarding oxygen tubing procedure and vision service follow-up | |
| Nurse #3 | Interviewed regarding urinary catheter privacy bag | |
| Director of Nursing | Interviewed regarding vision service documentation and wound care order completeness |
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