Quaboag Rehabilitation & Skilled Care Facility

In the surveyor’s words

From the most serious findings on record at Quaboag Rehabilitation & Skilled Care Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF557Nov 5, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 09/30/24 at approximately 6:50 P.M., Certified Nurse Aide (CNA) #1 removed Resident #1's meal tray from his/her room, despite his/her protests that he/she had not finished eating, and spoke to him/her in a loud and inappropriate manner. Several residents who were in the unit's common areas were also subjected to having to listen to CNA #1's verbal outbursts of profanity. Findings include: Review of the Facility Policy titled Resident Rights, dated as revised 05/27/22, indicated that employees shall treat all residents with kindness, respect and dignity. […]

• No harm, potential for more than minimal, isolatedF658Nov 5, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #2), who required a Foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside the body, the facility failed to ensure Resident #2 was provided with nursing care and treatment that met professional standards for quality, when Nursing staff did not follow up with his/her Urologist (a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract) after he/she missed a scheduled appointment to have his/her catheter changed, to obtain a new appointment or new orders for when it needed to be changed. […]

• No harm, potential for more than minimal, isolatedF690Apr 24, 2024

  Based on interview, record and policy review, the facility failed to provide appropriate care and services according to professional standards of practice for a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) for one Resident (#32) out of a total sample of 27 residents. Specifically, for Resident #32, the facility staff failed to provide suprapubic catheter care and services as ordered by the Physician to prevent catheter related complications when the catheter was leaking and was not flushed (manual injection with normal saline to clean or clear the catheter) and/or changed as indicated. […]

• No harm, potential for more than minimal, isolatedF756Apr 24, 2024

  Based on interview and record review, the facility failed to ensure that a medication regimen review recommendation was completed timely for one Resident (#56) out of a total sample of 27 residents. Specifically for Resident #56, the facility failed to ensure that a Consultant Pharmacist recommendation to complete an Abnormal Involuntary Movement Scale (AIMS - a rating scale designed to measure involuntary movement known as tardive dyskinesia (TD) which can be a side effect from a person receiving antipsychotic medication) was completed timely. Findings include: Resident #56 was admitted to the facility in August 2023 with a diagnosis of Psychophysical Visual Disturbances (visual hallucinations). […]

• No harm, potential for more than minimal, isolatedF757Apr 24, 2024

  Based on record review and interview, the facility failed to ensure that the medication regimen was free from unnecessary drugs for one Resident (#80) out of a total sample of 27 residents. Specifically, the facility staff failed to: -ensure that Resident #80 was free from an excessive dose of medication when an antibiotic (medication used to treat bacterial infection) medication that was Physician ordered to be given for five doses, resulted in the Resident being administered six doses in error. Findings include: Review of the facility's policy titled Medication Orders, revised January 2018, indicated the following: -Medication orders specify the quantity or duration (length of therapy). […]