COUNTRY GARDENS SKILLED NRSG & REHABILITATION CTR

Nursing Home Inspector

2045 GRAND ARMY HIGHWAY
SWANSEA, MA 02777
Bristol County
Phone: 508-379-9700
Provider Number: 225185
Last Inspection: 04/26/2017

About the Nursing Home

Number of Beds: 86
Number of Residents: 76
Beds Available: 10
Percent Occupancy: 88%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

14

Facility
22

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

14

2017
11

2016
9

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/26/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 6/8/2017
 
Failed To: Keep clinical records for an appropriate amount of time. Isolated : Minimal 3 6/8/2017
 
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Pattern : Minimal 4 6/8/2017
 
Failed To: Give the resident's representative the ability to exercise the resident's rights. Pattern : Minimal 4 6/8/2017
 

1/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain comfortable and safe temperature levels. Pattern : Minimal 4 2/19/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 2/19/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/19/2016
 

1/8/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give specialized rehabilitative services that are medically necessary by qualified personnel, when ordered by a doctor. Isolated : Minimal 3 2/22/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 2/22/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 2/22/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/6/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 3/31/2017
 

2/13/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Actual 4 4/17/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/17/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 4/17/2017
 

4/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 5/23/2016
 
Failed To: Make sure that doctors visit residents regularly, as required. Isolated : Minimal 3 5/23/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/23/2016
 

6/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Pattern : Actual 5 7/15/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Actual 5 7/15/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Actual 5 7/15/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 7/15/2015
 
Failed To: 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe Isolated : Minimal 3 7/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 76 104.26 96.79
Registered Nurses 1.14 0.68 0.89
Licensed Practical / Vocational Nurses 0.30 0.83 0.84
Certified Nursing Assistants 2.37 2.31 2.30
Total Staff Hours 3.82 3.82 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 2 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 42 92 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 77 94 95
of long-stay residents experiencing one or more falls with major injury 4 3 3
of long-stay residents who have depressive symptoms 2 2 2
of long-stay residents who lose too much weight 6 5 5
of long-stay residents who received an antianxiety or hypnotic medication 21 22 20
of long-stay residents who received an antipsychotic medication 20 15 18
of long-stay residents who self-report moderate to severe pain 5 5 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 25 19 18
of long-stay residents whose need for help with daily activities has increased 29 15 14
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 2 4 3
of low risk long-stay residents who lose control of their bowels or bladder 48 44 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 46 81 79
of short-stay residents who had an outpatient emergency department visit 16 13 11
of short-stay residents who made improvements in function 67 62 60
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 14 16 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 51 84 82
of short-stay residents who were rehospitalized after a nursing home admission 22 24 22
of short-stay residents who were successfully discharged to the community 34 51 56
of short-stay residents with pressure ulcers that are new or worsened 0 1 0