Melrose Healthcare
MELROSE HEALTHCARE in MELROSE, MA — inspection on April 9, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment.
The MDS also indicated Resident #8 was dependent on staff for self-care tasks.
Review of Resident #8's medical record indicated the Resident has active physician orders for two antipsychotic medications.
Review of Resident #8's medical record indicated a Roger's treatment plan that expired on [DATE].
When asked, the facility was unable to provide any documentation that Resident #8's Roger's treatment plan had been renewed and kept up to date by the facility.
During an interview on [DATE] at 1:48 P.M., the Social Worker said Resident #8 has a Roger's treatment plan for the use of anti-psychotic medication.
The Social Worker said she is responsible for ensuring Resident #8's Roger's order is kept up to date and if the facility wants to make changes, she would be the person responsible for contacting the lawyer to make a court appointment for the changes.
The Social Worker said she was unaware Resident #8's Roger's treatment plan was expired and needed to be renewed by the courts.
During an interview on [DATE] at approximately 8:00 A.M., the Corporate Nurse said the facility discovered Resident #8's Roger's treatment plan was expired on [DATE].
The Corporate Nurse said the social services department should have kept track of this treatment plan and ensured it was kept current and did not expire.
225329
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 225329 B.
Wing 04/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Melrose Healthcare 40 Martin Street Melrose, MA 02176
Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following:
-2.
When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including:
a.
How the resident's pacemaker was monitored (phone, office, internet);
1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes.
Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments.
During interview on 4/8/25 at 12:20 P.M., Resident #20 said he/she has a pacemaker.
On 4/6/25 at 12:36 P.M. and 4/8/25 at 12:23 P.M., the surveyor observed Resident #20's room, there was not a pacemaker monitor observed his/her room.
Review of Resident #20's hospital discharge summary, dated 10/3/24, indicated AV block (Atrioventricular block - type of heart block) status post pacemaker 3/2022.
The discharge summary also indicated the pacemaker checks will be remote on 10/23/24, 1/22/25 and 4/29/25.
Review of Resident #20's cardiac care plan, dated 10/6/24, indicated checks as ordered.
Review of Resident #20's nursing progress note, dated 10/23/24, indicated Resident has an appointment for remote MD visit (via phone) at 09:30 am [sic] but no call received.
Review of Resident #20's medical record failed to indicate this pacemaker check was ever rescheduled or that the Resident was scheduled for a cardiology appointment outside of the facility.
225329
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 225329 B.
Wing 04/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Melrose Healthcare 40 Martin Street Melrose, MA 02176
Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15.
This MDS indicated Resident #9 had two unstageable pressure ulcers.
This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred.
Review of Resident #9's medical record indicated he/she had been transferred and admitted to the hospital on 3/6/25 for bilateral heel osteomyelitis.
On 4/7/25 at 10:36 A.M., the surveyor observed Nurse #5 perform the wound dressing change on Resident #9's bilateral heels. Resident #9's right heel was observed to be the size of a [NAME] with a red wound bed and the left heel was also approximately the size of a [NAME] with black and tan wound bed.
During these wound dressing changes Nurse #5 did not perform any hand hygiene after removing gloves and before applying new ones during six out of eight glove changes.
During the other two glove changes, Nurse #5 used alcohol prep pads to sanitize and said this was because she forgot hand sanitizer.
During an interview on 4/7/25 at 11:14 A.M., Nurse #5 said she should have performed hand hygiene during all glove changes but did not.
Review of Resident #9's consultant Wound PA progress note, dated 1/6/25, indicated:
- Left heel unstageable deep tissue injury (DTI) pressure ulcer: not improved.
- Right heel unstageable deep tissue injury pressure ulcer: improved.
225329
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 225329 B.
Wing 04/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Melrose Healthcare 40 Martin Street Melrose, MA 02176
Review of Resident #149's most recent Minimum Data Set (MDS) indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have moderate cognitive impairment.
The MDS also indicated Resident #149 required substantial to maximal assistance with self-care and mobility tasks.
Review of the incident report dated 2/2/25 indicated the following:
-Witnessed fall in the main dining room.
Resident was ambulating with CNA's back to the main dining room after toileting.
Resident crossed (his/her) feet while walking and slipped to the floor. CNA assisted resident to the floor, no apparent injuries noted.
Resident ambulating at baseline. No c/o (complain of) pain.
Review of Resident #149's fall care plan indicated the following interventions:
-Rehab evaluate and treat as ordered or PRN (as needed), initiated 1/14/25.
-Ensure proper placement of feet prior to ambulation, initiated 2/2/25.
Review of the therapy screen log book for 2025 failed to indicate therapy had screened Resident #149 after this fall.
During an interview on 4/8/25 at approximately 2:30 P.M. the Director of Rehabilitation said she was unaware Resident #149 sustained a fall on 2/2/25 and never received a referral from nursing to evaluate the Resident.
Review of the Nurse Practitioner note dated 2/6/25 failed to indicate the Nurse Practitioner was notified of this fall.
Review of the incident report dated 3/23/25 indicated the following:
225329
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 225329 B.
Wing 04/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Melrose Healthcare 40 Martin Street Melrose, MA 02176