During a May 31 morning medication round, inspectors watched Nurse #1 give resident #9 just one tablet of Vitamin D3 when the doctor had ordered two. The nurse mixed MiraLAX powder into water for the resident, then left the room while the resident placed the cup — still containing the undissolved medication — on a bedside table.
"The surveyor observed that the Nurse exited the room without ensuring that the Resident drank all the MiraLAX medication," inspectors wrote.
Twenty minutes later, the same nurse attempted to check resident #4's blood pressure using only a cuff, without a stethoscope. When questioned, the nurse admitted she had forgotten her stethoscope but still documented a blood pressure reading of 127/68.
She then gave the resident an inhaled medication but failed to offer mouth rinsing afterward, despite doctor's orders requiring it to prevent fungal infections. The nurse also administered 100 micrograms of Vitamin B12 instead of the prescribed 500 micrograms.
When the nurse realized she needed to check the resident's heart rate, she walked around the unit asking staff for a watch. A nursing aide brought her a wall clock at 8:27 A.M.
The Director of Nursing told inspectors that obtaining a blood pressure reading "cannot be obtained with just a blood pressure cuff and without a stethoscope" and called the documented reading "an error."
At 8:45 A.M., the Unit Manager took over the medication cart from Nurse #1 and continued administering medications to other residents.
The facility's policy requires nurses to check medication labels three times to verify the right resident, medication, dosage, time and administration method. Vital signs must be verified before giving medications when necessary.
But the violations extended beyond medication errors. Inspectors found the facility positioned resident #27's bed flush against the wall, preventing the Alzheimer's patient from exiting on the right side. The facility had no doctor's order, care plan, or restraint assessment for this arrangement.
Unit Manager #1 told inspectors she "did not know why Resident #27's bed was against the wall" and wasn't sure if staff had assessed it as a potential restraint. A nursing aide said the bed was positioned that way because "the space in the room was small."
The Unit Manager later acknowledged "there should have been a restraint assessment performed, a Physician's order obtained, and a care plan put into place for the positioning of the right side of Resident #27's bed flush against the wall."
The facility also failed to properly screen resident #17 for mental health services. Despite hospital records showing the resident had depression, psychosis, and was prescribed antipsychotic medications, staff completed a screening form indicating no mental illness diagnosis.
The hospital referral form noted the resident had a "prior medical history of Mood Disorder-Depression" and psychiatric recommendations to continue Seroquel and use Haldol for agitation. But the facility's screening showed negative results.
The facility's Social Worker reviewed the hospital documentation with inspectors and admitted "the PASRR Level I screen was not accurate and a Level II evaluation was needed."
Care planning failures affected three residents. Staff never updated resident #8's catheter care plan when switching from a size 22 French Foley catheter to an 18 French suprapubic catheter. The Director of Nursing said "a Physician's order should have been obtained and the Resident's Urinary Incontinence Care Plan should have been revised for the correct catheter size but was not."
After resident #18 fell in December, sliding from an unlocked chair onto the floor, the interdisciplinary team never reviewed the incident or updated fall prevention interventions. The Director of Nursing confirmed "Resident #18's incident report for falls in 12/26/23 had not been reviewed by the IDT and no falls interventions had been put in place."
Resident #10 attended care plan meetings without being properly invited. Social Worker #1, who had worked at the facility for nine years, acknowledged that meeting notes contained no documentation showing the resident or family had been invited to three separate conferences.
"If there was no documentation then that meant the Resident and/or the RR/family had not been invited to the conference," she told inspectors.
The facility struggled with basic staffing requirements, failing to provide registered nurse coverage for eight consecutive hours on two Saturdays in May. The Administrator confirmed the facility had "no RN coverage for 5/4/24 and 5/11/24."
Nutritional oversight also broke down. When resident #3 lost 16.4 pounds in one month — a 10.49% weight loss — nursing staff failed to notify the physician or dietitian immediately. The registered dietitian discovered the weight change only when reviewing weekly reports.
The dietitian recommended lab work on April 23, but no tests were ordered. The nurse practitioner told inspectors she wasn't notified of the significant weight loss until April 24, when she was contacted only about adding nutritional supplements.
"The Resident's weight loss from 3/12/24 to 4/9/24 was concerning and that she was not notified of the Resident's weight loss," the nurse practitioner said.
The facility's MDS Coordinator, employed since December 2023, incorrectly coded two assessments for resident #27, failing to indicate the resident was receiving hospice services despite admission notes and progress reports confirming hospice care.
The coordinator admitted the assessments "were coded incorrectly because the assessments did not reflect that Resident #27 was receiving Hospice services."
The Director of Nursing acknowledged that "the process regarding weight assessment for Resident #3 was not followed and should have been."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverbend of South Natick from 2024-06-05 including all violations, facility responses, and corrective action plans.