Pioneer Valley Living And Rehab

In the surveyor’s words

From the most serious findings on record at Pioneer Valley Living And Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 13, 2023

  Based on clinical record reviews, observations, resident and staff interviews, and facility policy review, the facility failed to protect a vulnerable resident (Resident #22) from inappropriate sexual contact from another resident (Resident #9) while the staff sat at the nurses' station. Following the incident, Resident #9 continued to be allowed in Day Room with Resident #22. The staff reported that Resident #9 could walk independently throughout the facility and the facility did not always have staff in the common area near the nurses' station. In addition, the facility implemented an intervention to monitor Resident #9's location at all times but documented on it three times a day. During this time frame, Resident #9 had two documented instances of interaction with Resident #22. […]

• Immediate jeopardy, isolatedF689Jul 13, 2023

  Based on facility document review, clinical record review, and staff interviews the facility failed to protect residents from accidents and injuries by not providing a newly hired Temporary Nurse Aide (TNA)/Certified Nurse Aide (CNA) enough education to know which residents could go outside unsupervised and/or if a resident could get up after a fall before a nurse assessed them. After the TNA left the resident outside unsupervised and without a means to call for help, the resident fell hitting her head that resulted in a hematoma (a collection of blood outside of a blood vessel). Following the incident, the facility failed to provide formal education to all the staff of which residents could be outside unsupervised. […]

• Actual harm, isolatedF686Feb 6, 2025

  Based on observation, interview and record review the facility failed to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed, (Resident #31). At the time of survey, Resident #31 was found to be sitting in the recliner in his room for long periods of time with no pressure-reducing device on the seat. The resident had two open sores on his buttocks. The facility reported a census of 47 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He required moderate assistance with toileting hygiene, lower body dressing, and toileting transfers. His diagnoses included; renal insufficiency, peripheral vascular disease, and hip fracture. […]

• Actual harm, isolatedF689Feb 6, 2025

  Based on observations, record review, facility investigative file review, resident and staff interviews and policy review, the facility failed to ensure 2 of 3 residents (Resident #11 and #96) reviewed were free of accidents/hazards with transfers. The facility reported a census of 47 residents. Findings include: 1) The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 8/2/24, documented Resident #96 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested Resident #96 had mild cognitive impairment. Resident #96 did not exhibit behaviors during the review period nor did he reject care during the review period. He has impairments on both sides to bilateral upper and lower extremities and utilized a wheelchair. […]

• Actual harm, isolatedF760Feb 6, 2025

  Based on record review and staff interview, the facility failed to assure residents were free from significant medication errors for 1 of 22 residents reviewed, (Resident #30). The facility reported a census of 47 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 documented a diagnoses of Diabetes Mellitus (DM), renal insufficiency and hypertension. The MDS indicated the resident required the high risk drug class of insulin injections for DM management. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The Care Plan for Resident #30 showed the following related to DM: a. Diabetes medication of glucose tabs, glipizide and insulin ordered by the physician. b. […]