Riverbend of South Natick

In the surveyor’s words

From the most serious findings on record at Riverbend of South Natick, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jan 9, 2023

  Based on observation, policy review, interview, and record review, the facility failed to ensure its staff implemented appropriate infection control practices related to the use of Personal Protective Equipment (PPE) on two out of two units and also failed to implement a surveillance plan for the presence of Legionella. Specifically, the facility failed to: 1) ensure the proper use of wearing face masks while on the unit, 2) ensure the proper removal of face masks and cleaning of eye protection when exiting a resident room with a known COVID-19 infection, 3) provide trash receptacles inside of resident rooms who were on transmission based precautions, to allow for the removal of contaminated PPE prior to exiting the room on one of two units, 4) ensure staff wore the appropriate PPE to… […]

• No harm, potential for more than minimal, patternF880Aug 7, 2025

  Based on observations, interviews, and record review, the facility failed to ensure that appropriate infection prevention and control measures were followed for one Resident (#18) out of a total sample of 13 residents. Specifically, for Resident #18, the facility failed to implement and adhere to Contact Precautions to reduce the potential spread of infection when the Resident was diagnosed with Scabies (skin infection/rash caused by a parasitic mite, that can be spread by skin-to-skin contact) putting staff, other residents, and visitors at risk for the spread of infection. […]

• No harm, potential for more than minimal, patternF759Jan 9, 2023

  Based on record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. One of two nurses observed failed to administer medications, as ordered, for four of seven Residents (#16, #3, #6, #20) observed. The medication error rate was calculated at 18.52% with 27 opportunities for error. Findings include: 1. During an observation on 1/5/23 at 8:51 A.M., the surveyor observed Nurse #2 administer the following medications (along with other prescribed medications) to Resident #16: -Multivitamin one tablet by mouth. -Polyethylene Glycol (laxative) 3350 17 grams (gm) in 4 ounces of water. […]

• No harm, potential for more than minimal, isolatedF580Jun 5, 2024

  Based on record review and interview, the facility failed to notify the Physician of a significant change in condition for one Resident (#3) out of a total sample of 13 Residents. Specifically, the facility staff failed to notify the Physician/ Nurse Practitioner (NP) so treatment could be altered when Resident #3 was identified with significant weight loss by the Registered Dietician. Findings include: Review of the facility policy titled Weight Assessment and Intervention, undated, indicated: -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: >1 month - 5% weight loss is significant, greater than 5% is severe >3 months - 7.5% weight loss is significant, greater than 7.5% is severe >6 months - 10% weight loss is significant,… […]

• No harm, potential for more than minimal, isolatedF604Jun 5, 2024

  Based on observation, record review and interview the facility failed to ensure one Resident (#27) was free from a potential restraint, out of a total sample of 13 residents. Specifically, the facility failed to assess the use of the right side of the bed positioned flush against the wall, preventing Resident #27 from exiting the right side of bed, being used as a potential restraint. Findings include: Review of the facility policy titled Restraints, undated, indicated the following: -The intent of this policy is for each person to reach his or her practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. […]