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Deficiency Category | Inspection Date: 9/12/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 9/28/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 9/29/22 Complaint Reporting Period: 3/1/22 - 2/28/23 |
---|---|---|---|
Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
Quality of Life and Care Deficiencies | |||
Infection Control Deficiencies | |||
Resident Assessment and Care Planning Deficiencies | |||
Nursing and Physician Services Deficiencies | |||
Resident Rights Deficiencies | |||
Nutrition and Dietary Deficiencies | |||
Pharmacy Service Deficiencies | |||
Environmental Deficiencies | |||
Administration Deficiencies |
Date of last standard health inspection: | 9/12/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 3/12/24Read the full report (PDF) |
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Massachusetts: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care or services that was trauma informed and/or culturally competent. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/12/24 | 4/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 9/12/24 | 10/10/24 | 1 - Potential for minimal harm | Some |
Ensure services provided by the nursing facility meet professional standards of quality. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/12/24 | 3/12/24 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 3/12/24 | 3/4/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 9/12/24 | 10/10/24 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 9/28/23Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | No complaint inspections |
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Massachusetts: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and 24-hour emergency dental care for each resident. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Infection Control Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
No Resident Rights Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 9/28/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 9/29/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | No complaint inspections |
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Massachusetts: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide safe and appropriate respiratory care for a resident when needed. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Assist a resident in gaining access to vision and hearing services. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide or obtain dental services for each resident. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure services provided by the nursing facility meet professional standards of quality. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Allow residents to self-administer drugs if determined clinically appropriate. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 9/29/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Some |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 3/12/24 | 4/5/24 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 3/12/24 | 3/12/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 3/12/24 | 3/4/24 | 2 - Minimal harm or potential for actual harm | Few |
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |