Katzman Family Center for Living

In the surveyor’s words

From the most serious findings on record at Katzman Family Center for Living, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 16, 2021

  Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent falls for 1 Resident (#21) out of a total of 28 sampled residents. Subsequently, Resident #21 fell and sustained a nasal fracture and required 4 sutures. Findings include: Resident #21 was admitted to the facility in March 2021 with diagnoses including Alzheimer's disease, muscle weakness and [CONDITION(S)]. Review of Resident #21's most recent Minimum Data Set Assessment indicated that he/she severely cognitively impaired and requires assistance bathing, dressing and toileting. […]

• No harm, potential for more than minimal, patternF550Mar 9, 2023

  Based on observation record review and interview the facility failed to 1.) provide a dignified dining experience on 1 of 3 units and 2.) provide 1 Resident (#19) with (a) his/her meal timely and (b) identify Resident #19 in a dignified manner out of a total of 25 sampled Residents. Findings include: Review of the facility policy titled 'Quality of life-Dignity' with no revision date indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Staff shall speak respectfully to residents at all times including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. […]

• No harm, potential for more than minimal, patternF604Dec 16, 2021

  Based on observation, record review and interview the facility failed to assess 2 Residents (#51 and #93) for the use of pillows beneath a fitted sheet, and 2 Residents (#52 and #21) for the use of a reclining (Geri) chair as potential restraints out of a total sample of 28 residents. Findings include: Review of the facility policy titled Use Of Restraints and not dated, failed to indicate that a device that has the potential to restrain a person will be assessed to determine if the device actually acts as a restraint, for that person, prior to the application of the device. 1. […]

• No harm, potential for more than minimal, patternF656Dec 16, 2021

  Based on observation, interview and record review, the facilit failed to implement the plan of care for 3 Residents (#16, #56 and #81) out of a total sample of 28 residents. Findings include: 1. For Resident #16, the facility failed to implement his/her fall care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #16 was admitted to the facility in June 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #16's most recent Minimum Data Set (MDS) dated [DATE] revealed that Resident #16 had a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15 which indicated that he/she had moderate cognitive impairment. The MDS also indicated Resident #16 was dependent on staff for all daily tasks. […]

• No harm, potential for more than minimal, patternF880Dec 16, 2021

  Based on observation, record review and interview the facility failed to ensure practices to prevent the potential spread of infection by failing to perform hand hygience and failing to wear personal protection equipment. Findings include: Review of the facility's policy, entitled COVID-19 Infection Control Protocol, dated as revised November 30, 2021 indicated the facility is commiteed to preventind the spread of COVID-19 infections and adheres to the standards set by the state and federal government as well as Centers of Disease Control and Massachusetts Department of Public Health. All employess regardless of vaccination status must wear facemasks while in the facility at all times. Review of the facility policy entitled Influenza, Prevention and Control , not dated indicated under b. […]