Leominster Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Leominster Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 2, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from physical abuse and mental anguish, when on 06/11/24 during the evening shift (3:00 P.M. to 11:00 P.M), Resident #1 refused to transfer to bed, he/she became combative with staff and in response, Certified Nurse Aide (CNA) #1 physically restrained Resident #1, to which Resident #1 said stop, you're hurting me! CNA #1 yelled at Resident #1 telling him/her he was the captain, and forced Resident #1 to transfer into bed against his/her will. […]

• Actual harm, isolatedF656May 23, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Activity of Daily Living Care Plan indicated he/she required the assistance of one to two staff members for ambulation, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her plan of care related to mobility and care needs. On 04/09/23, Certified Nurse Aide (CNA) #3, left Resident #1 standing alone on a wet floor in his/her room while she went to get supplies to clean his/her floor. Resident #1 slipped, fell , and complained of left wrist pain and was later transferred to the Hospital Emergency Department for further evaluation where he/she was diagnosed with a non-displaced left wrist fracture. […]

• Actual harm, isolatedF689May 23, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of one to two staff members for ambulation and whose Care Plan indicated he/she had a potential for falls related to impulsiveness, poor safety awareness, and weakness, the Facility failed to ensure he/she was provided with the appropriate level of assistance required to maintain his/her safety, while in the presence of an environmental risk factor (wet floor), in an effort to prevent incident/accidents resulting in injury. On 04/09/23, Certified Nurse Aide (CNA) #3 left Resident #1 standing alone on a wet floor in his/her room while she went to get supplies to clean his/her floor. […]

• No harm, potential for more than minimal, widespreadF909Jun 27, 2023

  Based on record review and interview, the facility failed to inspect all resident beds annually for the [AGE] year, including mattresses, frames, and bedrails for possible areas of entrapment as required. Findings include: Review of the facility's policy titled, Bed Safety and Bed Rails, dated August 2022, included: - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. - The Maintenance department provides a copy of inspections to the Administrator . Review of the facility's Center Bed Rail Assessment Tracking Log, undated, included no evidence that all resident beds, including mattresses, frames, and bedrails had been assessed for possible areas of entrapment in 2022. […]

• No harm, potential for more than minimal, widespreadF880Oct 7, 2021

  Based on record review and interview, the facility failed to maintain an Infection Surveillance Program as required for the months of August, September, and October 2021. Findings include: Review of the Infection Surveillance Program log for 2021 showed no evidence of documentation for the months of August, September, or October 2021. During an interview on 10/07/21 at 12:58 P.M., the Administrator said there was no infection surveillance conducted or documented for the months of August, September, or October 2021.