Care Village at West Roxbury

In the surveyor’s words

From the most serious findings on record at Care Village at West Roxbury, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF865Nov 10, 2022

  Based on record review and interview the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) program. Findings include: The facility policy titled Quality Assurance and Performance Improvement (QAPI), dated as revised 12/6/21, indicated the following: * QAPI is a comprehensive program by which the facility identifies problems or issues early on, develops a plan to address the root causes of the problems and prevent adverse events throughout the system while involving the entire team is using the data to understand quality and work to improve performance. * The facility will incorporate the following five elements of a Quality Assurance and Performance Improvement plan: 1. […]

• No harm, potential for more than minimal, patternF656Nov 14, 2025

  Based on record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed for two Residents (#59, #) out of a total sample of 19 residents. Specifically,For Resident #46, the facility failed to ensure a resident- centered personalized care plan was developed for a pacemaker.For Resident #59, the facility failed to ensure a resident-centered personalized care plan was developed for a pacemaker. Findings include: Review of facility policy titled Pacemaker, care of a Resident with a, undated, indicated the following: -Documentation: For each resident with a pacemaker, document the following in the medical record upon admission: 1. The name, address and telephone number of the cardiologist. 2. Type of pacemaker c. Date of implant. d. […]

• No harm, potential for more than minimal, patternF550Nov 7, 2023

  Based on observation, record review and interview the facility failed to ensure four Residents (#8, #13, #53 and #28) were provided a dignified existence, out a total sample of 25 residents. Specifically, 1) For Residents #8 and #13 the facility failed to provide facial hair removal, and 2) For Residents #53 and #28 the facility failed to serve their meals in a timely manner. Findings include: Review of the facility policy titled Dignity, dated 12/6/21, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be always treated with dignity and respect. 3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 12. […]

• No harm, potential for more than minimal, patternF677Nov 7, 2023

  Based on interview, record review and observations the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to five Residents (#2, #14, #50, #28,#16), out of a total sample of 25 residents. Specifically, the facility failed to provide assistance with meals for dependent residents for five Residents (#2, # 14, #50, #28, #16). Findings include: Review of the facility policy titled, Activities of Daily Living, dated 12/22, indicated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. d. […]

• No harm, potential for more than minimal, patternF699Nov 7, 2023

  Based on record review and interview the facility failed to develop a plan of care for Post Traumatic Stress Disorder (PTSD) for two Residents (#60 and #21) who had an active diagnosis for PTSD out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Trauma Informed Care, dated 12/21/22, indicated The facility will ensure that all residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the individuals. […]