Mayflower Place Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mayflower Place Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 12, 2024

  Based on observation, record review, and staff interview, the facility failed to store, prepare and serve food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label, date, and store food products in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Safe Handling for Food Brought in From Visitors, dated effective ,d+[DATE], indicated but was not limited to: - It is [Facility Name's] policy to assist residents in properly storing and safely consuming foods brought into the center for residents by visitors. […]

• No harm, potential for more than minimal, widespreadF880Aug 12, 2024

  Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Ensure proper COVID-19 outbreak testing procedures were implemented for 3 of 3 facility staff members reviewed representing 2 of 2 COVID-19 affected units; 2a. Ensure staff rapid antigen COVID-19 testing (BinaxNOW) was conducted in a manner that is consistent with current standards of practice and manufacturer's instructions for use for 3 of 3 staff members observed; and b. […]

• No harm, potential for more than minimal, widespreadF761Jun 15, 2023

  Based on observation, policy review, and interview, the facility failed to ensure that all medications were properly stored and labeled in accordance with currently accepted professional principles on two of two units reviewed with four of four medication carts reviewed. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised January 2018, indicated but was not limited to the following: Expiration Dating: -Certain medications or package types such as multiple dose injectable vials and ophthalmics require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency -Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. […]

• No harm, potential for more than minimal, widespreadF812Jun 15, 2023

  Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was stored, labeled, dated and maintained under sanitary conditions in the main kitchen walk-in refrigerator and freezer; 2. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination; and 3. Wear hair restraints in the main kitchen during meal preparation and service. Findings include: Review of the 2022 Food Code by the U.S. […]

• No harm, potential for more than minimal, widespreadF867Jun 15, 2023

  Based on record review, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes from concerns brought forth from resident council meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated as revised October 2013, indicated the following: Feedback, Data Systems and Monitoring: -Monitoring care and services -Collecting data from various sources -Tracking, investigating and monitoring adverse events and action plans to prevent reoccurrence Performance Improvement Projects (PIPs) -Conducts… […]