Care Village At Parkway

transferred to the Hospital Emergency Department on 09/21/25.Review of Resident #1's Hospital Record, dated 09/21/25, also indicated he/she had a Deep Tissue Injury (DTI) on his/her right heel upon admission to the Hospital.Further review of Resident #1's Medical Record indicated there was no documentation to support that his/her Physician was notified of the pressure injury on his/her right heel.

During an interview on 11/17/25 at 08:58 A.M., The Director of Nurses (DON) said Nurse Supervisor #1 should have notified Resident #1's physician or the on-call physician of the new pressure injury on his/her right heel but had not.On 11/17/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 10/02/25, which addressed the area(s) of concern as evidenced by:A. 09/30/25, The Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that nursing notifies the physician of any new skin alteration to determine if a treatment order is necessary, that a progress note is written in the resident's medical record documenting this notification including details of any new order.B. 09/30/25, The Regional Director of Clinical Operations conducted a Facility wide audit of all skin assessments.C. 09/30/25, The Regional Director of Clinical Operation ensured that notification was made to the providers of any newly identified skin concerns, and any new orders were implemented.D. 09/30/25, The Director of Nurses (DON)/designee re-educated licensed staff and CNAs to the Facility's policy Change in Condition or Status Notification and educated licensed staff to document a progress note that included physician notification for any Resident change in condition.E. 10/02/25, Resident #1 was re-admitted to the Facility, the Physician was notified of his/her skin alterations, and a Plan of Care was developed and implemented including treatment to his/her right heel pressure injury.F.

The DON/designee will conduct daily audits of all skin checks performed to ensure any newly identified skin integrity concerns have been reported to the provider and the notification has been documented in the medical record.G.

The DON/designee will bring the results of the audits to the QAPI committee monthly for three months or until the desired outcome is achieved.H.

The DON/designee is responsible for ongoing compliance.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Care Village at Parkway

1190 Vfw Parkway Boston, MA 02132

SUMMARY STATEMENT OF DEFICIENCIES