Renaissance Manor on Cabot

In the surveyor’s words

From the most serious findings on record at Renaissance Manor on Cabot, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF730Oct 7, 2024

  Based on record review, and interview, the facility failed to complete a performance review at least once every 12 months for four Certified Nurses Aides [CNA's] (#1, #2, #4 and #5) out of four employee records reviewed. Specifically, the facility failed to complete annual performance evaluations for Certified Nurses Aides (CNA's) #1, #2, #4 and #5 as required placing the facility residents at risk for unevaluated delivery of care. Findings include: Review of the facility policy titled Performance Appraisal, dated 12/1/07 with revision date of 7/1/22, indicated: -Managers will meet with their employees at least annually to conduct performance reviews or have performance-based conversation. -This policy applies to all employees. […]

• No harm, potential for more than minimal, widespreadF881Oct 7, 2024

  Based on interview, and record review, the facility failed to ensure that an Antibiotic Stewardship Program (ASP-a coordinated effort to improve how antibiotics are prescribed and used in a Heathcare setting) was in place for antibiotic use protocols and monitoring. Specifically, the facility failed to conduct antibiotic monitoring for the facility, placing residents at risk for complications related to antibiotic usage. Findings include: Review of facility policy titled Antibiotic Stewardship, dated 12/31/16 with revision date of 10/24/22 and review date on 11/15/22, indicated: -Centers (the facility) will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. […]

• No harm, potential for more than minimal, patternF658Oct 7, 2024

  Based on interview, record and policy review, the facility failed to follow professional standards of practice relative to the transcription of Physician orders for one Resident (#15), of five residents reviewed for unnecessary medications, out of a total sample of 12 residents. Specifically, the facility failed to that ensure laboratory orders and Psychiatric Consult recommendation obtained by the Physician after a Medication Regimen Review (MRR) conducted by the Consultant Pharmacist were completed for Resident #15. […]

• No harm, potential for more than minimal, patternF725Oct 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staffing levels with the appropriate competencies and experience to provide nursing and related services to the facility residents. Specifically, the facility failed to: 1. provide staffing levels in accordance with the facility assessment for 23 out of 36 days for the period 9/1/24 -10/6/24, placing the facility residents at risk for impeded delivery of care and inability to meet the specific needs and concerns of each resident. 2. provide a sufficient number of nursing staff to provide basic care and respond timely per Resident Council concerns voiced. 3. […]

• No harm, potential for more than minimal, patternF757Oct 7, 2024

  Based on interview, record and policy review, the facility failed to ensure that one Resident (#8), of five applicable residents reviewed for unnecessary medications, out of a total sample of 12 residents, did not recieve medications outside of the Physician ordered parameters. Specifically, for Resident #8, the facility failed to ensure that Tramadol (an opioid medication used to relieve moderate to moderately severe pain) was administered within the parameters (moderate and severe pain) prescribed by the Physician. […]