Adviniacare Newton Wellesley

In the surveyor’s words

From the most serious findings on record at Adviniacare Newton Wellesley, in the surveyor’s own words.

• Actual harm, widespreadF725Dec 19, 2023

  Based on observations, record review and interview, the facility failed to 1.) ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs and to timely assist residents with dining needs on 4 of 4 units and 2.) failed to ensure 2 Residents (#54 and #64) were provided with assistance, as needed, for meals. Findings included: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. […]

• Actual harm, widespreadF837Dec 19, 2023

  Based on interview and record review, including review of the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was sufficiently staffed per the Facility Assessment; 2. ensuring quality of care related to abuse was maintained for one Resident (#62); and 3. ensuring quality of care related to safety & hazards in the facility was maintained for two Residents (#30 and 35) out of a total sample of 29 residents. […]

• Actual harm, patternF607Dec 19, 2023

  Based on observations, interviews and record reviews the facility failed to implement their Abuse policy for 7 Residents (#62, #44, #16, #28, #11, #5 and #13) out of a total sample of 29 residents. Specifically 1. For Resident #62, the facility failed to implement the abuse policy following three incidents of Resident #62 being struck by peers in the 1 [NAME] Unit dining room on 12/12/23, 12/13/23 and 12/18/23. 2. For Resident #44, the facility failed to implement the abuse policy when he/she struck a peer in the 1 [NAME] Unit dining room on 12/12/23. 3. For Resident #16 the facility failed to implement the abuse policy after he/she struck a peer, on 12/13/23 and 12/18/23, in the I [NAME] Unit dining room. 4. […]

• Actual harm, patternF699Dec 19, 2023

  Based on observation, interviews, record and policy reviewed for one Resident (#13) out of a total sample of 29 residents, the facility failed to ensure residents with a history of trauma received trauma informed care in accordance with professional standards. Specifically, the facility failed to implement Resident #13's trauma-informed plan of care which indicated he/she should have female care givers for personal care. Findings included: Review of the facility policy titled, Trauma Informed Care, revised 10/22/22, indicated to ensure residents, who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice which are culturally-competent and account for experiences and preferences, and address the needs of trauma… […]

• No harm, potential for more than minimal, widespreadF880Dec 12, 2024

  Based on record review and interview, the facility failed to 1.) follow the water management plan for Legionella prevention and 2.) failed to implement the infection prevention and control program. Specifically, 2a.) The facility failed to implement enhanced barrier precautions for a Resident (#11) with a wound. 2b.) The facility failed to ensure Nurse #1 performed a dressing change according to acceptable standards of practice. Findings include: 1.) Review of the facility Water Management Program For Building Water Systems: Site Management Plan, dated May 1, 2018, indicated the following: - 2.4. Monitoring and Verification Plan: This section defines the site-specific monitoring and verification plan. - 2.4.1 Cold Water Services * Task: Legionella Culture Test. […]