Aspen Hill Rehabiliation & Healthcare Center

cannot recall the exact phrases CNA #5 said to her, but remembers it was her body language and

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that a CNA was kind of rushed and the Resident was upset with the transfer and that the CNA was not taking her time.

The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs.

The Administrator said that she asks residents verbatim if they feel like they have been abused.

The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance.

The Administrator said the Resident initially reported it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care.

During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no.

Review of the medical record failed to indicate any information regarding the incident.

Review of the Healthcare Facility Reporting System failed to indicate the incident was reported on or around 11/27/24.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff

forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1.

Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt.

The Social Worker documented Resident #1 reports his/her arm is still sore.

There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5.

Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulner (the long bone of the forearm) with indeterminate age (time of fracture could not be determined).

Review of the Employee Performance Improvement Notification, dated 12/16/24, 6 days after the alleged incident, indicated CNA #5 was suspended from the facility pending investigation of the incident that occurred with Resident #1.

Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

coded based on the RAI (resident assessment instrument) manual.

minimal harm

Review of Resident #106's health status note, dated 1/12/25 at 2:33 A.M., indicated: -Note Text: At 1:00 A.M., the CNA (Certified Nursing Assistant) found the resident on the floor in a praying position.

This writer responded immediately to the resident's room.

Assessment performed; Resident was safely removed from the floor.

On 1/14/25 at 8:03 A.M., 1:54 P.M., 3:13 P.M., and at 4:24 P.M., and on 1/15/25 at 6:48 A.M., and 7:27 A.M., the surveyor observed Resident #106 in his/her bed without bilateral fall mats on both sides of bed.

During an interview on 1/15/25 at 7:30 A.M., CNA #3 said that Resident #106 does not utilize fall mats. CNA #3 and the surveyor searched the Resident's room and CNA #3 was unable to locate any fall mats.

During an interview on 1/15/25 at 7:55 A.M., Nurse #5 said that Resident #106 had a fall on 1/12/25, and Nurse #5 is not aware of Resident #106 requiring fall mats.

Nurse #5 said that Resident #106 is a high risk for falls.

During an interview on 1/15/25 at 9:01 A.M., Unit Manager #3 said that Resident #106 is a high risk for falls.

Unit Manager #3 reviewed Resident #106's care plan and Unit Manager #3 said that the intervention for fall mats should be implemented if it is on the plan of care.

During an interview on 1/15/25 at 3:44 P.M., the Director of Nursing (DON) said Resident #106 has altered mental status and he/she is cognitively impaired.

The DON said that Resident #106 has had multiple falls, and nursing should implement the care plan for bilateral fall mats.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of Resident #112's active nutrition care plan, initiated on 1/12/25, indicated the following: -I have a nutritional problem or potential nutritional problem r/t (related to) reported weight loss, PMHx (past medical history) significant for malignant CA (cancer), malnutrition, dysphagia w/ PEG (percutaneous endoscopic gastrostomy), a feeding tube that goes directly into the stomach), anemia, depression, HLD (hyperlipidemia), GERD (Gastroesophageal reflux disease), and anxiety. -Interventions in Resident #112's care plan include to obtain weights at ordered intervals.

Review of Resident #112's Nutritional Risk Assessment, dated 12/31/24, indicated the following: -Recommendations and Plan: Weekly weights x4 from admission.

Review of Resident #112's physician's orders indicated the following: -Weight on admission then weekly every Friday, dated initially 12/30/24, then updated on 1/10/25.

Review of Resident #112's documented weights in the Electronic Medical Record (EMR) indicated the following: -12/28/24: 149.2 pounds (lbs.) -12/30/24: 146.0 lbs. -1/15/25: 141.5 lbs.

Review of the medical record failed to indicate that Resident #112 was weighed as ordered between 12/30/24 and 1/15/25.

Further review of the medical record failed to indicate that Resident #112 refused to be weighed.

During an interview on 1/15/25 at 12:02 P.M., Unit Manager #3 said that weights should be obtained on admission and weekly for four weeks, unless otherwise specified by a physician's order.

She said that Resident #112 should have been weighed weekly and monitored per physician's orders.

Unit Manager #3 said that given Resident #112's recent history he/she is at risk for weight loss and malnutrition.

She said that someone should have noticed that the Resident was not weighed since 12/20/24 but they did not.

During an interview on 1/15/25 at 2:01 P.M., the Director of Nurses said that it is the facility policy to weigh residents on admission and weekly for four weeks.

She further said that she would expect that nurses are obtaining resident weights per physician orders.

During an interview on 1/16/25 at 7:57 A.M., the Dietitian said that she would expect staff to obtain weights as ordered for appropriate weight management.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of Resident #111's nursing progress note, dated 1/13/25, indicated: -Resident up 5.2 lbs since 1/9.

Review of Resident #111's physician's order, dated 1/14/25, indicated: 2 view chest x-ray (CXR) and a kidneys ureters and bladder (KUB) - diagnosis: lower extremity edema and abdominal distention.

Review of Resident #111's nursing progress note, dated 1/15/24, indicated: -Resident with weight fluctuations, trending up since 1/9/25 in setting of CHF.

During an interview on 1/16/25 at 8:34 A.M., Nurse #10 said that Resident #111 has congestive heart failure and requires daily weights.

Nurse #10 said she couldn't remember why she documented the weight as refused on Friday 1/10/25 on the MAR, but the daily weight should have been obtained.

During an interview on 1/16/25 at 8:39 A.M., Nurse #11 said that Resident #111 has congestive heart failure and required daily weights for monitoring.

Nurse #11 said the scale was broken and she was unable to obtain Resident #111's weight on Saturday 1/11/25.

During an interview on 1/15/25 at 1:28 P.M., Nurse #7 said he worked the overnight shift over the weekend and he said the scale was not consistently working over the weekend.

Nurse #7 said the scale had last been serviced in 2023.

Nurse #7 said he was unable to obtain Resident #111's weight for 2 days (1/12/25 and 1/13/25) and Nurse #7 said he was not sure if there was another scale in the facility to use.

During an interview on 1/15/25 at 3:22 P.M., Nurse #8 said the scale on the unit was not working correctly and there have been issues with the scale over the last few months.

Nurse #8 said that a few residents, including Resident # 111, have congestive heart failure and their weights needs to be monitored closely.

During an interview on 1/15/25 at 12:08 P.M., Unit Manager #3 said she was not aware nursing was not obtaining Resident #111's weights because the scale was broken.

Unit Manager #3 said that Resident #111 has congestive heart failure and is receiving a diuretic.

Unit Manager #3 said that staff should have used a scale from a different unit to obtain Resident #111's weight.

During an interview on 1/15/25 at 3:39 P.M., the Director of Nursing (DON) said she was not aware the scale was broken until she read the nursing progress notes.

The DON said Resident #111 has congestive heart failure and has orders for daily weights and should have obtained the weights using a different scale.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

can monitor and ensure the correct settings every shift, but that Resident #473 does not have one.

with air mattresses is to be set by weight or comfort, but that their should be a physician's order with

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of Resident #106's plan of care related to intravenous (IV) therapy, dated 1/3/25, indicated: - Monitor dressing at IV insertion site daily and change as ordered and as needed.

Review of Resident #106's physician's order, dated 1/3/25, indicated: -Daptomycin Intravenous Solution Reconstituted 500 milligrams (mg) (Daptomycin), Use 400 mg intravenously one time a day for bacteremia (infection in the flood) until 1/18/25.

Review of Resident #106's physician's order, dated 1/3/25, indicated: - IV:(Midlines and PICCs) Document baseline mid-upper arm circumference, check arm circumference as needed, one time only for admission process until 1/3/2025. - IV: (Midlines and PICCs) Document baseline external length of IV catheter, check external length with each dressing change and as needed one time a day every 7 day(s) document external length and as needed. - IV: (Midline, PICC, CVAD) Change Transparent Dressing on admission and then every 7 days; Caps to be changed during dressing change. one time only for best practices on admission and one time a day every 7 day(s) for best practices.

Review of Resident #106's January 2025 Medication Administration Record (MAR) indicated on 1/10/25, Nurse #3 changed the transparent dressing as ordered by the physician.

However, based on the surveyor's observation on 1/14/25 at 8:03 A.M., the dressing was last changed on 1/2/25.

During an interview on 1/15/25 at 8:15 A.M., Nurse #3 said that she has never changed a PICC line dressing, and she does not know how to change them.

Nurse #3 said she thinks only Registered Nurses can change PICC line dressings and she is a Licensed Practical Nurse.

Nurse #3 said that when orders are signed off on the Treatment Administration Record (TAR) they should be completed.

During an interview on 1/15/25 at 8:55 A.M., Unit Manager #3 said she observed the PICC line on 1/14/25 and the PICC line was dated 1/2/25.

The Unit Manager #3 said that the dressing should have been changed every 7 days, and measurements should have been obtained but they were not.

During an interview on 1/15/25 at 3:47 P.M., the Director of Nursing said PICC lines dressings need to be changed every 7 days, and she said the nurse's completing the dressing changes should obtain PICC line measurements.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

During an interview on 1/15/25 at 9:23 A.M., Social Worker (SW) #1 said that the documents titled Social Services Assessment - V 10, dated 3/11/24, are not accurate and should reflect that Resident #7 has PTSD. SW #1 then said that a care plan should either reflect resident specific triggers and interventions or should reflect that the resident/responsible party was unable to respond.

During an interview on 1/15/25, at 8:44 A.M. the Director of Nursing said that it is her expectation that the care plans are resident specific.

She said that she would expect that the trauma informed care plans would contain specific triggers and interventions to relieve a triggered episode.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 4 2024 (July 1 - September 30) indicated the following: -This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's 'Facility Assessment Tool, not dated, indicated at the staffing plan the following: Total Number Needed or Average or Range of Staff: -Licensed nurses providing direct care = 15. -Nurse Aides = 30. -Hours Per Patient Day (HPPD) = 3.20 total direct care staff.

Review of the facility staffing records indicated that only one out of 12 weeks, during the FY Quarter 4 2024, did the facility meet the 3.20 HPPD required to adequately care for the residents in the facility.

During an interview on 1/16/25, at approximately 9:00 A.M., the Administrator said that the facility had difficulty recruiting last year, but has since been able to staff appropriately using on call nursing management when needed.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

During an interview on 1/14/25 at 12:25 P.M., Unit Manager #3 said medications should not be stored undated or expired and must be removed from the medication cart.

During an interview on 1/15/25 at 12:30 P.M., the Director of Nursing (DON) said medications must be dated and labeled appropriately when opened according to the manufacturer's instructions and said expired medications must be removed.

During an observation on 1/14/25 at 12:51 P.M., the following medications were observed on the A-Unit medication Cart 2: -One 887mL (milliliter) Bottle of Liquid Protein opened and undated, therefore unable to determine an expiration date.

Manufacturer instruction indicates to discard the bottle after 90 days of opening. -One bottle of fluticasone nasal spray (nasal spray contain steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine the expiration date.

Manufacture instructions to discard after using 120 sprays. -4 packages of ipratropium Bromide and albuterol sulfate (an inhaled medication to treat breathing conditions) 0.5 mg/ 3mg ml (milligrams/milliliter) open and undated, therefore unable to determine an expiration date.

Manufacturer instructions indicate once removed from foil pouch individual vials should be used within one week. -One Bottle Tuberculin Purified Protein Derivative (Mantoux) Tubersol.

Multi-dose vial (50 Tests) 5 Tuberculin units per test.

Open and dated 12/19/24, unrefrigerated.

Manufacturer instructions indicate to store refrigerated after opening.

During an interview on 1/14/25 at 1:05 P.M., Nurse # 5 said medications should have been dated when opened and said the Tuberculin solution needs to be refrigerated after opening.

During an interview on 1/14/25 at 1:07 P.M., Unit Manager #3 said medications should not be stored undated or expired and must be removed from the medication cart.

Unit Manager #3 said Tuberculin solution should be dated when opened and stored in the medication room in the refrigerator.

During an interview on 1/15/25 at 12:35 P.M., the Director of Nursing (DON) said medications must be dated and labeled appropriately when opened according to the manufacturer's instructions and said expired medications must be removed.

The DON said she would expect staff to know that Tuberculin must be stored in the refrigerator.

• On 1/15/25 at 8:14 A.M., the surveyor observed a medication cart unlocked on the Dementia Unit

and was able to open and access it.

There were no staff present.

On 1/15/25 at 8:17 A.M., Nurse #1 walked down the hallway and returned to the medication cart.

Nurse #1 said that the cart was supposed to be locked when unattended.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of the facility policy titled Availability of Services, Dental, dated as revised August 2007 indicated that dental services are available to all residents requiring routine and emergency dental care. Resident #71 was admitted to the facility in May 2024 with diagnoses including Parkinson's Disease, malnutrition and depression.

Review of the most recent Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #71 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam indicating intact cognition.

The MDS further indicated Resident #71 did not have any obvious broken/carious teeth.

During an interview on 1/15/25, at 2:05 P.M., Resident #71 said that he/she has not seen the dentist while a resident at the facility but that if it would help him/her to chew he/she would want to see the dentist. Resident #71 also said that he/she had not been asked if he/she wanted to see a dentist. Resident #71 showed the surveyor his/her teeth.

The surveyor observed multiple upper and lower teeth missing and obvious carious teeth that had dark discoloration on all remaining teeth.

Review of the facility document titled Admission/readmission Screener-V 10 dated 5/15/24, indicated that Resident #71 had missing teeth.

Further review failed to indicate Resident #71 had carious teeth.

Review of the current active care plan indicated a focus for I have oral/dental health problems R/t (related to ) poor dental hygiene with interventions including coordinate arrangements for dental care, transportation as needed/as ordered.

Review of the medical record failed to indicate that Resident #71 had been seen by a dentist.

Further review failed to indicate that Resident #71 had been asked if he/she wanted to a dentist.

During an interview on 1/15/25 at 3:11 P.M., the Director of Nursing said that Resident #71 should have had a dental consult.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of Resident #93's medical record indicated he/she was seen by the dentist on 5/7/24 with the following assessment and recommendations: Patient presents for periodic exam.

Patient complains that bottom teeth hurt occasionally, comes and goes for the last two months.

Doesn't specifically say which area Recommend ext. (extract) non-restorable teeth prior to fabrication of dentures: #23, 24, 25, 26, 31.

Patient states he/she is afraid of needles and would like extractions done under sedation.

Refer to OS (oral surgeon) for extraction of teeth.

Recommend follow up after referral to OS.

Recommend FMX (dental x-ray) for insurance approval of partial denture - will ask for X-rays to be sent from OS.

Discussed healing time prior to fabrication of dentures.

Review of the medical record failed to indicate any nursing notes or follow up information related to the recommendations made by the dentist on 5/7/24.

Further review of Resident #93's medical record failed to indicate consent forms were signed for tooth extraction or any other follow-up to schedule the extractions of teeth.

Review of the nursing oral assessment, dated 7/22/24, indicated that Resident #93 did not have dentures present, has fractured/missing teeth and soft plaque build-up. No nursing interventions needed at present.

During an interview on 1/15/25 at 10:18 A.M., Nurse #2 said Resident #93 does not have dentures and was unaware he/she needed teeth extractions or needed dentures.

During an interview on 1/15/25 at 10:35 A.M., Unit Manager #2 reviewed Resident #93's medical chart with the surveyor and said Resident #93 should have been seen by the oral surgeon and dental recommendations were not followed up on from the 5/7/24 dental visit.

Unit Manager #2 said she was unaware that Resident #93 needed teeth extractions or needed dentures and said the process should have been documented in the medical record and communicated with the clinical team.

Unit Manager #2 said there is no documentation in the nursing progress notes regarding the dental visit and said Resident #93 has not been seen by an oral surgeon as of 1/15/25.

During an interview on 1/15/25 at 11:32 A.M., the Director of Nursing said she and the medical records department will manage the follow up process for dentures and a health drive status update report is submitted.

The Director of Nursing reviewed the report and said she has no documentation that the recommendations were communicated or that the process was implemented for Resident #93 after the 5/7/24 dental visit, and said the facility is responsible for ensuring all recommendations are reviewed and followed up on.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of Resident #93's active care plan failed to indicate a plan of care for vision impairment.

Review of Resident #93's eye doctor consult dated 12/5/24 indicated the following: -plan: Cataract surgery recommended -Referral: cataract ophthalmology; note to nurses please call [outpatient eye doctor's office] and schedule initial cataract evaluation and removal.

Review of the medical record failed to indicate that facility staff scheduled the recommended follow up for evaluation for cataract surgery.

During an interview on 1/16/25 at 7:47 A.M., Unit Manager #2 said that when consultant recommendations are made, it is reviewed with the resident's health care proxy and the attending provider and then orders are put into place.

She said a hard copy of the consult is provided to the Unit Managers to review with providers.

During a phone interview on 1/16/25 at 8:11 A.M., an employee at the outpatient eye doctor's office [which was specifically recommended from the consulting eye doctor in the facility] said that the office has not received any referrals or inquiries to schedule evaluations for cataract surgery for Resident #93.

During a follow up interview on 1/16/25 at 8:26 A.M., Unit Manager #2 said she was not aware of the recommendations for evaluation for cataract surgery needed for Residents #32, #28 or #93.

She reviewed the eye doctor consults and said referrals should have been made.

During an interview on 1/16/25 at 9:11 A.M., the Director of Nurses said that her expectation is that recommendations from consulting providers are followed up on within a week, and the recommendations for Resident #93 were not.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

the nurse who obtained the blood pressure reading is documenting the wrong arm in the computer

from.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of the QAPI plan indicated that education was completed, but not further audits or plan to keep resident's safe was implemented.

Two surveyors reviewed the QAPI plan, which was blank and incomplete.

The Administrator said she may have resident safety interviews, but could not produce them during survey.

The Administrator produced a QAPI plan after the survey was conducted with a target date of 11/5/24, 3 weeks prior to the initial incident.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

During an interview on 2/21/25 at 9:46 A.M., the Infection Preventionist said she was not aware that Resident #2i had MRSA and said contact precautions should have been implemented.

During an interview on 2/21/25 at 10:24 A.M., with the Director of Nursing (DON) and the Administrator, the DON said staff must follow infection control guidelines and she expects contact precautions to be initiated and followed.

The DON said Resident #2i should have been placed on contact precautions for MRSA and said a sign and a PPE cart should have been in place.

The Administrator said she expects staff to implement infection control protocols and expects the staff to follow infection control guidelines when providing care.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Based on record review and interviews, the facility failed to offer the COVID 19 (Coronavirus disease)

vaccinations during new hire orientation.

Findings include: A review of the facility policy titled, Employee Infection and Vaccination Status, dated as revised January 2024, indicated the following: -Prior to or upon an employee's duty assignment, the facility will assess the status of an employee's vaccination against infectious conditions.

Vaccinations are documented in the employee health record. -Employees will be current with mandated vaccinations prior to performing direct resident care. -Employees are offered or provided with vaccinations per state or local agency policies/regulations. -Employees are provided with education materials to make informed decisions for non-mandated vaccinations. If declined, a declination form is completed and placed in the employee's health record.

A review of 6 employee health records indicated 2 out of the 6 employees had not been vaccinated for COVID 19.

A review of the informed consent forms provided by the Director of Nurses for Nurse #3 and Activities Assistant #1 indicated the following: -Nurse #3 was provided the informed consent and educated on the COVID 19 vaccination side effects.

Nurse #3 refused to accept the vaccination; Nurse #3 signed the form but did not date it. -Activities Assistant #1 was provided the informed consent and educated on the COVID 19 vaccination side effects.

Activities Assistant #1 refused to accept the vaccination.

Activities Assistant #1 signed and dated the form on 1/15/25.

During an interview and record review on 1/16/25 at 8:15 A.M., the Director of Nurses reviewed Nurse #3's and Activities Assistant #1's informed consent forms.

She said Nurse #3 signed the consent form on 1/15/25 but did not date it.

She said the Activities Assistant #1 signed the consent form on 1/15/25.

The Director of Nurses said both employees should have been offered the COVID 19 vaccination during their new hire orientation but were not.

During an interview and record review on 1/16/25 at 8:30 A.M., the Human Resources Manager said Nurse #3 attended new hire orientation on 11/26/24 and the Activities Assistant #1 attended new hire orientation on 10/1/24 and 10/2/24.

During a telephone interview on 1/21/25 at 11:04 A.M., the Administrator said both Nurse #3 and Activities Assistant #1 have worked in the facility since they attended new hire orientation.

225404 01/16/2025

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/5/24, indicated Resident #7 scored a 15 out of 15, indicating intact cognition.

Review of the active diagnoses list indicated Resident #7 has a diagnosis of PTSD.

Review of the facility document titled Social Services Assessment - V 4, dated 5/12/23, indicated that Resident #7 did not experience a past trauma.

Review of the current active care plan indicated a focus for PTSD related to family discord/abuse.

Further review indicated the following interventions:

-Accept my current level of function. Be consistent, positive, honest and nonjudgmental while working with me.

-Assist me with identifying coping/calming mechanisms to manage anxiety or correct misunderstandings conditioned at the time of trauma/stress, such as relaxation techniques, deep breathing, visualization, removing myself from the situation.

-My strengths are: enjoys playing guitar and is very good at it.

-Provide spiritual/religious support as needed.

Further review failed to indicate triggers or interventions specific to Resident #7.

2. Resident #85 was admitted to the facility in February 2024 with diagnoses including PTSD, dementia and depression.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/23/24, indicated Resident #85 has a diagnosis of PTSD.

The MDS indicated Resident #85 scored a 6 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment.

Review of the current active care plan indicated a focus for PTSD related to (blank).

225404

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225404 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830

Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition.

Review of the MDS indicated Resident #95 requires partial to moderate assistance with all activities of daily living.

During review of the a grievance filed on 11/27/24, written by the Administrator, indicates Resident #95 reported to the Unit Manager that a C.N.A. (certified nursing aide) did not follow her preferences for transferring.

The grievance also indicated Resident had reported that a CNA pulled his/her arm too hard during a transfer.

Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (staff member) on his/her (the Resident) preferences for transfer.

225404

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225404 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Hill Rehabiliation & Healthcare Center 190 North Avenue Haverhill, MA 01830