DEN-MAR HEALTH AND REHABILITATION CENTER

Nursing Home Inspector

44 SOUTH STREET
ROCKPORT, MA 01966
Essex County
Phone: 978-546-6311
Provider Number: 225456
Last Inspection: 12/06/2016

About the Nursing Home

Number of Beds: 76
Number of Residents: 70
Beds Available: 6
Percent Occupancy: 92%
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

 

25

Facility
14

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

25

2016
26

2015
24

2014

Medicare Ratings

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

 

Details by Inspection Date

12/6/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give the resident's representative the ability to exercise the resident's rights. Isolated : Minimal 3 1/6/2017
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 1/6/2017
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 1/6/2017
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 1/6/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 1/6/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 1/6/2017
 
Failed To: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Isolated : Minimal 3 1/6/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 1/6/2017
 

12/31/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Isolated : Minimal 3 2/14/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 2/14/2016
 
Failed To: Maintain comfortable sound levels. Pattern : Minimal 4 2/18/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 2/14/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 2/14/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 2/14/2016
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Widespread : Minimal 5 2/14/2016
 

9/17/2014 Inspection

 
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 10/10/2014
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 10/10/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/10/2014
 
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 10/10/2014
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/10/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 10/10/2014
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 10/10/2014
 

Complaint Investigation Deficiencies

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

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 70 93.73 96.79
Registered Nurses 0.62 0.85 0.89
Licensed Practical / Vocational Nurses 0.77 0.91 0.84
Certified Nursing Assistants 1.59 2.24 2.30
Total Staff Hours 2.98 4.01 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 0 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 74 90 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 94 95
of long-stay residents experiencing one or more falls with major injury 7 3 3
of long-stay residents who have depressive symptoms 3 2 2
of long-stay residents who lose too much weight 11 7 5
of long-stay residents who received an antianxiety or hypnotic medication 17 20 20
of long-stay residents who received an antipsychotic medication 27 18 18
of long-stay residents who self-report moderate to severe pain 3 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 30 20 18
of long-stay residents whose need for help with daily activities has increased 27 15 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 2 4 3
of low risk long-stay residents who lose control of their bowels or bladder 38 59 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 31 79 79
of short-stay residents who had an outpatient emergency department visit 3 10 11
of short-stay residents who made improvements in function 68 62 60
of short-stay residents who newly received an antipsychotic medication 5 2 1
of short-stay residents who self-report moderate to severe pain 11 14 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 65 82 82
of short-stay residents who were rehospitalized after a nursing home admission 25 22 22
of short-stay residents who were successfully discharged to the community 56 58 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0