Thomas Upham House

In the surveyor’s words

From the most serious findings on record at Thomas Upham House, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Oct 18, 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. Specifically, the facility failed to: 1. Maintain a complete and accurate system of surveillance and to analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program; 2. For Resident #28, perform COVID-19 rapid antigen testing at the first sign and symptom of COVID-19 in accordance with the standard; 3a. […]

• No harm, potential for more than minimal, widespreadF801Apr 14, 2021

  Based on record review and staff interviews, the facility failed to designate a person who met the minimum qualifications to serve as a Director of Food and Nutrition Services to ensure the function of the department. The facility dietitian works six to eight hours a week. Findings include: During an interview on 4/13/21 at 10:40 A.M., the Food Service Director (FSD) said he was hired ten months ago as the Food Service Manager (FSM) and cook. The FSM said he is ServSafe certified and has ten years of experience as a cook for his qualifications. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2021

  Based on policy review, observations, staff interviews, and record review, the facility failed to ensure staff: 1) stored food in a safe and sanitary manner (labeled and dated open containers of perishable food, disposed of expired food); 2) monitored the temperature of cooked food at each meal; and 3) properly sanitized and cleaned the thermometer when checking food temperatures to prevent potential foodborne illness in the facility. Findings include: Review of the facility's policy titled Preventing Foodborne Illness-Food Handling, 2001 MED-Pass, revised [DATE], indicated the following: -Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 1. This facility recognizes that the critical factors implicated in foodborne illnesses are: a. […]

• No harm, potential for more than minimal, patternF605Nov 20, 2025

  Based on record review and interview, the facility failed to ensure for one Resident (#5), out of a total sample of 17 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure a physician's order for as needed (PRN) Trazodone (antidepressant) contained an indication for use, included a duration and failed to ensure the prescriber reassessed the Resident's condition and documented a clinical rationale for the continued use of PRN Trazodone as required.Findings include:Review of the facility's policies titled Psychotropic Drug Policy, last updated June 2015 and Antipsychotic Medication Use, last revised… […]

• No harm, potential for more than minimal, patternF658Nov 20, 2025

  Based on observation, record review, and interviews, the facility failed to ensure professional standards of practice were followed for one Resident (#41) from a total sample of 17 residents. Specifically, the facility failed to obtain a physician's order for the use of oxygen therapy (O2) prior to its use.Findings include:Review of the facility's policy titled Oxygen Concentrator, last revised 1/2016, included but was not limited to:-Verify the Physician's order.Review of [NAME] NURSING PROCEDURES, 8th edition, indicated:-verify the practitioner's order for oxygen therapy, because oxygen is considered a medication or therapy and should be prescribedDOCUMENTATION record the date and time of oxygen administration, the type of delivery device, the oxygen flow rate, the patient's vital signs,… […]