Heather Court.

“An unlocked laptop displaying a resident's Medication Administration Record (MAR) containing confidential information was observed on top of the medication cart in Unit B, violating record confidentiality requirements.”

“Narcotic logbooks were found in unlocked side slots of medication carts, unattended and not confidential. Department representative observed these items during facility inspection.”

“Resident #1 was observed performing a sexual act over roommate (Resident #2) in their shared bedroom. This is a repeat violation from 5/7/24 and 8/15/24. Both residents have a diagnosis of dementia.”

“Residents #3, #4, and #5 engaged in a physical altercation in a common area. Resident #3 shoved walker into Residents #4 and #5's legs, hit Resident #5 on the head, and Resident #5 struck back with a shoe.”

“Staff A and Staff B did not complete annual fire safety education by a fire safety expert or person trained by a fire safety expert for the 2023 training year.”

“The enabler bar attached to the bed in resident room C109 was not securely attached to the bed frame. The bar could be pulled back and forth and the mattress had slid to the side creating a gap. This is a repeat violation from 12/19/23.”

“In the Cambridge Unit's laundry room, three spray bottles were found with handwritten labels instead of original manufacturer labels: one labeled 'Odoban Air Freshner', one labeled 'Dawn Water', and one labeled 'Spray and Wash' and 'Peroxide and Multi Surface'. This is a repeat violation from 12/19/23.”

“The trash can in the AB pantry area and the trash can in the Beswick kitchen did not have lids on them during the initial facility walk through, allowing potential penetration by insects and rodents.”

“A collection of lint was found behind the dryer and along the exhaust vents behind the dryer in the Avon laundry area, creating a fire hazard near a heat source.”

“Prescribed medications were not available in the home at time of inspection: Resident #6's medication for an unspecified condition and Resident #8's powder medication for an unspecified condition were missing. Additionally, Resident #9's Glucometer did not have a corresponding reading for a blood glucose level documented in the Medication Administration Record. This is a repeat violation from 12/19/23.”

“The home failed to report to the Department's regional office an incident involving a resident fall that resulted in fractures of the 8th and 9th ribs diagnosed by mobile x-ray within 24 hours as required.”

“A resident was physically abused when another resident hit them on the side of the head three times during an altercation over a cup of tea.”

“During noon medication administration, a staff member mistakenly administered one resident's medications to another resident. The error was discovered immediately when the staff member attempted to initial the medication administration record for the correct resident.”

“On 7/21/24 during noon medication administration, a resident was mistakenly administered multiple medications belonging to another resident instead of following the prescriber's orders for that resident's noon medications.”

“A resident admitted to the secured dementia facility did not have a cognitive preadmission screening completed within 72 hours prior to admission as required. The screening was completed on 5/21/24 but the resident was admitted on a later date.”

“The home used correction fluid on physician call reports found in a resident's record, which violates the requirement that entries be permanent, legible, dated and signed by the staff person making the entry.”

“Staff member grabbed a resident by the upper right arm and yelled at them, resulting in bruising to the resident's upper right arm. This constitutes physical abuse and mistreatment in violation of the requirement that residents may not be physically or verbally abused.”

“Enabler bars for two residents were not securely attached to bed frames, posing a possible hazard to residents.”

“Laundry detergent was stored in clear Tupperware containers without the manufacturer's label, violating requirements for poisonous materials storage.”

“A prescribed PRN medication for Resident 2 was not available at the time of inspection, indicating failure to properly implement procedures for safe storage and availability of medications.”

“Resident 3's RASP (Resident Assessment and Support Plan) was not signed by the resident or assessor.”

“Resident 4 was admitted to the SDU without a support plan being completed within the required 72-hour timeframe.”

“Resident 3's RASP was not updated to reflect that the resident is utilizing an enabler bar on their bed. This is a repeat violation from 1/5/2023.”

“Staff Member A had only 15.5 training hours verified for the 2022 training year, which does not meet the required 6 hours of annual dementia care training plus 12 hours of additional annual training for direct care staff in a secured dementia care unit.”