BLUE HILLS HEALTH AND REHABILITATION CENTER LLC

Nursing Home Inspector

1044 PARK STREET
STOUGHTON, MA 02072
Norfolk County
Phone: 781-344-7300
Provider Number: 225444
Last Inspection: 09/07/2017

About the Nursing Home

Number of Beds: 92
Number of Residents: 84
Beds Available: 8
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
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

 

16

Facility
20

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

16

2017
16

2017
16

2016

Medicare Ratings

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

 

Details by Inspection Date

9/7/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 10/22/2017
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 10/22/2017
 
Failed To: Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. Isolated : Minimal 3 10/22/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 10/22/2017
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Isolated : Minimal 3 10/22/2017
 

3/16/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 4/17/2017
 
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 4/17/2017
 
Failed To: Provide activities to meet the interests and needs of each resident. Widespread : Minimal 5 4/17/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 4/17/2017
 

9/13/2016 Inspection

 
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 10/4/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 10/4/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 10/4/2016
 
Failed To: Give or get specialized rehabilitative services per the patient's assessment or plan of care. Isolated : Minimal 3 10/4/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/4/2016
 

Complaint Investigation Deficiencies

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

9/26/2017 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 11/10/2017
 

8/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/15/2015
 
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 : Minimal 4 10/15/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Actual 4 10/15/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 10/15/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/15/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 10/15/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 10/15/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 10/15/2015
 
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 10/15/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/15/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 10/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 84 95.41 96.79
Registered Nurses 0.75 1.00 0.89
Licensed Practical / Vocational Nurses 0.81 0.70 0.84
Certified Nursing Assistants 2.36 2.41 2.30
Total Staff Hours 3.92 4.11 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 1 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 90 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96 95 95
of long-stay residents experiencing one or more falls with major injury 3 4 3
of long-stay residents who have depressive symptoms 7 2 2
of long-stay residents who lose too much weight 5 5 5
of long-stay residents who received an antianxiety or hypnotic medication 18 17 20
of long-stay residents who received an antipsychotic medication 35 17 18
of long-stay residents who self-report moderate to severe pain 0 3 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 28 19 18
of long-stay residents whose need for help with daily activities has increased 43 16 14
of long-stay residents with a catheter inserted and left in their bladder 0 1 1
of long-stay residents with a urinary tract infection 5 3 3
of low risk long-stay residents who lose control of their bowels or bladder 59 53 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 63 74 79
of short-stay residents who had an outpatient emergency department visit 13 11 11
of short-stay residents who newly received an antipsychotic medication 0 60 60
of short-stay residents who self-report moderate to severe pain 7 1 1
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 66 13 14
of short-stay residents who were rehospitalized after a nursing home admission 30 81 82
of short-stay residents who were successfully discharged to the community 15 24 22
of short-stay residents with pressure ulcers that are new or worsened 0 55 56