Adviniacare At Northbridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Northbridge, Massachusetts.
- Location
- 85 Beaumont Drive, Northbridge, Massachusetts 01534
- CMS Provider Number
- 225248
- Inspections on file
- 18
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Adviniacare At Northbridge during CMS and state inspections, most recent first.
A facility failed to provide a dignified dining experience when a CNA stood over a resident while assisting with a meal, contrary to the facility's policy requiring staff to sit at eye level with residents. The incident was confirmed through observations and interviews with the CNA, Unit Manager, and ADON.
The facility failed to issue SNF ABN notices to two residents who no longer qualified for Medicare Part A skilled services, as required by CMS standards. This oversight left the residents unaware of their potential financial liability for continued services.
A facility failed to conduct required quarterly care plan meetings and ensure a resident's participation in the care planning process. The resident, diagnosed with Bipolar Disorder and cognitively intact, was unaware of any care plan meetings. The facility's policy requires resident involvement and interdisciplinary team (IDT) conferences every 90 days, but no documentation of such meetings or participation was found for 2024.
A resident on antiplatelet medication was observed with multiple bruises, but the LTC facility failed to assess, document, or implement interventions to manage the bruising. Despite policy requirements for weekly skin checks, the staff did not document the bruises, and there was no care plan to address the risk of bruising and bleeding. Interviews revealed a lack of consistent monitoring and communication among staff.
A resident admitted with heart failure, hyperlipidemia, atrial fibrillation, and hypertension did not receive four critical medications due to the facility's failure to accurately reconcile their medication list. The omission was discovered when the resident's healthcare proxy raised the issue, and the Assistant Director of Nurses confirmed the error. Despite the facility's offer to address the missed medications, the resident chose to leave against medical advice.
The facility failed to follow safe food handling practices during a meal tray pass, as observed by surveyors. A nurse and a unit manager used a plastic scoop from a multi-use container of powdered thickening agent without performing proper hand hygiene. The unit manager admitted to not following hand hygiene protocols, which are required by the facility's policies on hand hygiene and dining.
A resident with an ESBL-producing bacterial infection in their urine was not provided with appropriate Contact Precautions, as required by the facility's policy. Staff members, including two CNAs, failed to perform hand hygiene and wear gowns and gloves when entering and exiting the resident's room, despite the presence of signs indicating the need for such precautions. The Infection Preventionist confirmed that these measures were necessary to prevent the spread of infection.
A resident with a history of Type Two Diabetes Mellitus and Acute Respiratory Failure was not provided a Pneumococcal Vaccine despite consenting to it upon admission. The facility's policy requires offering the vaccine to residents aged 65 and older, following CDC guidelines. The resident had received previous doses of PPSV23 and PCV13 but was overdue for a new dose. The Infection Preventionist confirmed the resident's vaccination status was not up-to-date, highlighting a failure in policy adherence.
A resident with Type Two Diabetes Mellitus was inaccurately coded in the MDS Assessments as receiving insulin injections, when in fact, they only received Trulicity, a non-insulin diabetes medication. This error was confirmed by the MDS Nurse after reviewing the resident's MAR, revealing a failure in accurately documenting the resident's medication administration.
A resident with multiple psychiatric diagnoses refused medication and meals for several days, leading to a hospital transfer. The Facility failed to notify the resident's legal Guardian of these significant changes and the transfer, despite having the correct contact information.
A resident with multiple psychiatric diagnoses was improperly discharged to a hospital ED without the required documentation or notice. The Physician did not order the discharge and questioned the Facility's claim of inability to meet the resident's needs, given that they had admitted and cared for the resident for a week prior.
The Facility failed to provide a properly completed written Notice of Transfer or Discharge to a resident and their legal guardian at the time of discharge. The resident, with multiple mental health diagnoses and moderately impaired mental status, was discharged to the Hospital Emergency Department without notice, and the Facility refused to permit the resident to return. The resident's guardian was not informed of the discharge or the resident's right to a 30-day notice and the right to appeal the discharge.
A facility failed to ensure a safe and orderly transfer for a resident with a legal guardian, discharging the resident to a hospital 60 miles away despite instructions to transfer to a closer hospital. The resident was sent alone in a wheelchair van, and the facility did not notify the guardian or allow the resident to return.
The facility failed to provide a resident's legal guardian with a written notice of the bed-hold policy when the resident was transferred to the hospital. Despite the facility's policy requiring such notice, the administrator confirmed it was not given because the resident was discharged to the hospital.
A resident with multiple psychiatric diagnoses was not permitted to return to the Facility after an ED evaluation, despite the hospital's determination that the resident did not need hospitalization. The Facility's leadership cited the resident's refusal to accept care, food, and medications as reasons for not allowing the return, contrary to their own discharge/transfer policy.
The facility failed to develop an effective discharge plan for a resident with complex mental health needs and a court-appointed guardian. The resident was transferred to a hospital 60 miles away without timely informing the guardian or honoring their request for a closer hospital. The facility did not create a post-discharge plan or obtain a physician's order for discharge, as required.
A resident with multiple diagnoses was transferred to the hospital without a complete discharge summary. The Facility failed to document a recapitulation of the resident's stay, course of illness/treatment, final summary of status, or a post-discharge plan of care involving the resident and their guardian.
A resident with severe OCD did not receive timely psychiatric consultation or intervention, leading to continued distress and unmet mental health needs. The resident refused care, including medication and meals, and exhibited behaviors related to their OCD, which were not adequately addressed by the facility.
A Facility failed to comply with professional standards for social workers when an LSWA documented services in a resident's EHR using the credentials of an LICSW. The LSWA admitted to using the LICSW's username and password, and the LICSW had not worked in the Facility during the resident's stay. The Administrator was unaware of this practice.
A Facility failed to maintain accurate medical records when a Licensed Social Work Associate documented services using another staff member's credentials. The resident had multiple diagnoses, and the discrepancy was discovered through interviews and record reviews.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident, as observed by a surveyor. The incident involved a Certified Nurses Aide (CNA) standing over a resident while assisting with a breakfast meal, contrary to the facility's dining policy. The policy, last revised in April 2023, specifies that staff should sit next to residents while assisting them with meals. During the observation, the resident was reclining in bed with the head elevated, and the CNA was standing over the resident. Interviews with the CNA, Unit Manager, and Assistant Director of Nurses confirmed that the CNA should have been at eye level with the resident, as per the facility's policy.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN) to two residents, which is required when a resident no longer qualifies for Medicare Part A skilled services. This notice is crucial as it informs residents of their potential financial liability if they choose to continue receiving services that Medicare may not cover. The facility's policy, aligned with the Centers for Medicare and Medicaid Services (CMS) standards, mandates the issuance of SNF ABNs to ensure residents are aware of their financial responsibilities. Resident #213, admitted in April 2024, and Resident #215, admitted in February 2024, both continued to stay in the facility after their Medicare benefits ended on June 13, 2024, and February 24, 2024, respectively. However, the facility did not provide the required SNF ABN notices for these residents, as confirmed by the Social Worker during an interview. This oversight meant that the residents were not informed of their potential financial obligations, which is a violation of the facility's policy and CMS requirements.
Failure to Conduct Care Plan Meetings and Ensure Resident Participation
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was provided the right to participate in the care planning process. Specifically, the facility did not conduct quarterly care plan meetings as required for the resident in March and June 2024. The interdisciplinary team (IDT) also failed to meet quarterly in 2024 to review the resident's plan of care. The facility's policy mandates that each resident should be involved in the development and review of their care plan, and IDT conferences should occur at 90-day intervals. The resident, who was admitted in June 2023 with a diagnosis of Bipolar Disorder and was cognitively intact with a BIMS score of 12 out of 15, reported being unaware of any care plan meetings. A review of the resident's clinical record showed no documented evidence of participation in the care planning process or IDT meetings for 2024. Additionally, there were no records of meetings or refusals to participate documented. The social worker confirmed the absence of progress notes or sign-in sheets indicating that care plan meetings had been held or that the resident and/or their representative had participated, as per facility policy.
Failure to Monitor and Document Bruising in Resident on Antiplatelet Medication
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident who was prescribed antiplatelet medication, specifically Aspirin, which increases the risk of bruising and bleeding. The resident, who was severely cognitively impaired and had multiple diagnoses including Peripheral Vascular Disease and Chronic Kidney Disease, was observed by a surveyor to have multiple bruises on the upper extremities. Despite these observations, the facility staff did not adequately assess or document the bruising, nor did they implement interventions to reduce the risk of further bruising or bleeding complications. The facility's policy required weekly skin checks and documentation of any skin issues, but the staff failed to adhere to these guidelines. The resident's skin evaluations did not reflect the bruises observed by the surveyor, and there was no documentation in the clinical record regarding the bruises. Interviews with the nursing staff revealed a lack of consistent monitoring and documentation practices, with one nurse admitting to not documenting bruises unless they appeared to require treatment. This inconsistency in monitoring and documentation left other staff without a baseline for comparison, hindering effective care. Interviews with the Unit Manager and Assistant Director of Nursing highlighted a lack of awareness and communication regarding the resident's frequent bruising. The Unit Manager acknowledged that any resident with bruising should have a care plan with interventions to reduce the risk of bruising and bleeding, which was not in place for this resident. The Assistant Director of Nursing confirmed that the bruising should have been assessed and monitored, but no such instructions or interventions were implemented, indicating a systemic failure in the facility's care processes.
Failure to Reconcile Medications Leads to Significant Error
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by the inaccurate reconciliation of the resident's medication list upon admission. The resident, who was admitted with diagnoses including heart failure, hyperlipidemia, atrial fibrillation, and hypertension, did not receive four critical medications during their stay. These medications, which were documented in the resident's hospital history and physical report, included Eliquis, Buspirone, Atorvastatin, and Metoprolol. The omission of these medications was not identified until the resident's healthcare proxy brought it to the attention of the nursing staff. The Assistant Director of Nurses confirmed that the resident should have been provided with the medications listed in the hospital report during their stay. The failure to administer these medications was a significant medication error, as it required medical intervention and posed a risk of morbidity or mortality. Despite the facility's offer to start the missed medications and monitor for adverse effects, the resident and their healthcare proxy chose to leave the facility against medical advice.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe sanitation and food handling practices, as observed by surveyors during a meal tray pass on the [NAME] Nursing Unit. Two staff members, a nurse and a unit manager, were seen using a plastic scoop from a multi-use container of powdered thickening agent without following proper hand hygiene protocols. The unit manager was observed on two occasions reaching into the container with a bare hand to retrieve the scoop, adding the thickening agent to a resident's liquid, and then returning the scoop to the container without performing hand hygiene. Similarly, the nurse was observed performing the same actions without hand hygiene. During an interview, the unit manager admitted to using the scoop from the canister and acknowledged that hand hygiene was not performed during the meal tray pass. The unit manager confirmed that hand hygiene should have been conducted before and after handling the scoop. The facility's policies on hand hygiene and dining, which require infection control practices during meal service, were not followed, leading to the deficiency.
Failure to Implement Contact Precautions for Resident with ESBL Infection
Penalty
Summary
The facility failed to implement Transmission-Based Precautions for a resident with an ESBL-producing bacterial infection in their urine, which posed a risk for transmission of infection to others. The facility's policy required Contact Precautions for residents with communicable diseases, but staff did not adhere to these guidelines. The resident, who was cognitively intact and always incontinent of urine, was on antibiotics for a urinary tract infection and required Contact Precautions every shift. Observations by the surveyor revealed that staff members, including CNA #1 and CNA #2, did not perform hand hygiene or wear the required gown and gloves when entering and exiting the resident's room. CNA #1 touched various surfaces in the room and accessed clean linen carts without following proper infection control measures. Similarly, CNA #2 entered the room and touched surfaces without donning protective equipment. Both CNAs acknowledged the importance of these precautions but failed to implement them, as confirmed by the Infection Preventionist, who stated that all staff should follow these protocols to prevent the spread of infection.
Failure to Administer Pneumococcal Vaccine to Consenting Resident
Penalty
Summary
The facility failed to provide a Pneumococcal Vaccine to a resident who was not up-to-date with their vaccination status, despite the resident's consent to receive it. The facility's policy, revised in February 2023, mandates offering Pneumococcal Vaccines to all residents aged 65 and older unless they have already been vaccinated, do not need a booster, or have a medical contraindication. The Centers for Disease Control and Prevention (CDC) guidelines specify that adults aged 65 or older who have received previous doses of PCV13 and PPSV23 should receive a dose of PCV20 or PPSV23 to complete their series, with specific timing requirements for administration. The resident in question was admitted to the facility in May 2022, with a history of Type Two Diabetes Mellitus and Acute Respiratory Failure. The resident had received a PPSV23 vaccine in 1996 and a PCV13 vaccine in 2014. Upon admission, the resident consented to receive the Pneumococcal Vaccine, but there was no evidence in the clinical record that the vaccine was administered or that it was medically contraindicated. The Infection Preventionist confirmed that the resident was overdue for the vaccine according to CDC guidelines, indicating a lapse in the facility's adherence to its vaccination policy.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) Assessments for a resident diagnosed with Type Two Diabetes Mellitus. The resident was admitted to the facility in February 2024 and was prescribed Trulicity, a medication used to treat diabetes that is not classified as insulin. The MDS Assessments for February and May 2024 incorrectly indicated that the resident received insulin injections during the observation periods, despite the resident only receiving Trulicity injections. The error was identified through a review of the resident's Medication Administration Records (MAR) and confirmed during an interview with the MDS Nurse. The nurse acknowledged that the MDS Assessments were inaccurately coded, as the resident did not receive any insulin injections during the specified observation periods. This discrepancy highlights a failure in accurately documenting the resident's medication administration, specifically regarding the type of diabetes medication received.
Failure to Notify Guardian of Resident's Condition and Hospital Transfer
Penalty
Summary
The Facility failed to notify the legal Guardian of a resident who refused daily antipsychotic medication and meals for several days and was subsequently transferred to the hospital. The Facility's Resident Rights Policy and Notifications Policy require notifying the resident's designated representative of significant changes in the resident's condition or treatment. However, the Guardian was not informed until the resident had already been transferred to the hospital. The Guardian was first notified by the Facility's Admission Director, who mentioned the possibility of hospital transfer but did not inform her that the transfer had already occurred. The Guardian later received notification from the hospital itself. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's medical record indicated a court-appointed Legal Guardian since April 2023. Despite the resident's refusal to eat and take medication being documented in nursing, social work, and physician progress notes, there was no documentation of the Facility notifying the Guardian. The Licensed Social Work Associate attempted to contact the Guardian but used an incorrect email address. The Guardian provided evidence of prior email correspondence with the Facility, indicating that the Facility had the correct contact information but failed to use it appropriately.
Improper Discharge of Resident Without Adequate Documentation
Penalty
Summary
The Facility failed to permit Resident #1 to remain in the Facility or to ensure that, prior to discharge, Resident #1's Physician documented the danger posed by the Facility's failure to discharge Resident #1 and the Resident's needs which could not be met in the Facility, as required. Resident #1, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The Resident's mental status was moderately impaired, and he/she refused care daily but was independent with eating, hygiene, and was continent of bowel and bladder. On 3/12/24, the Facility discharged Resident #1 to the Hospital ED without providing the required documentation or notice to the Resident or the Guardian. The Physician stated that he did not give an order to discharge Resident #1 and questioned the Facility's claim of inability to meet the Resident's needs, given that they had admitted and cared for him/her for a week prior to the discharge. The Facility's records lacked documentation to support that they identified specific care needs they could not meet or the attempts to meet those needs.
Failure to Provide Proper Notice of Transfer or Discharge
Penalty
Summary
The Facility failed to provide a properly completed written Notice of Transfer or Discharge to a resident and their legal guardian at the time of discharge. The resident, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's mental status was moderately impaired, and they refused care daily. Despite these conditions, the Facility discharged the resident to the Hospital Emergency Department without a written Notice of Transfer or Discharge, and the Facility refused to permit the resident to return. The resident's guardian was not informed of the discharge or the resident's right to a 30-day notice and the right to appeal the discharge. Interviews with the Hospital Director of Regulatory Affairs, Hospital Case Manager, Hospital Social Worker, and the resident's Guardian confirmed that no written notice was provided. The Facility's Administrator and Licensed Social Work Associate also confirmed that no Notice of Transfer or Discharge was issued to the resident or their Guardian. The Licensed Social Work Associate mentioned that a notice was faxed to the Long Term Care Ombudsman office, but not to the resident or their Guardian.
Failure to Ensure Safe and Orderly Transfer
Penalty
Summary
The facility failed to ensure a safe and orderly transfer for a resident with a court-appointed legal guardian. Despite the guardian's explicit instructions to transfer the resident to the closest hospital, the facility discharged the resident to a hospital 60 miles away. The resident was sent alone in a wheelchair van with all personal belongings, and the emergency department was not prepared for the resident's arrival. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the facility in March 2024. On the day of the transfer, the resident was reported to be out of control, not eating, not accepting medications, and defecating in the room. The physician ordered a transfer to the emergency department for evaluation, but the facility did not follow the guardian's instructions regarding the hospital destination. The facility did not notify the guardian about the transfer or the decision to discharge the resident. Upon arrival at the hospital, the emergency department staff contacted the facility, which then refused to allow the resident to return. The facility staff justified their actions by stating that a prior arrangement had been made with the referring hospital for the resident's return if the admission did not go well. However, the physician confirmed that no discharge order had been given.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to ensure that the legal guardian of a resident was provided with a written notice specifying the duration of the facility's bed-hold policy at the time of the resident's transfer to the hospital. The facility's bed-hold policy, revised in October 2022, mandates that such notice be given to the resident or their representative to ensure continuity of care. However, during an interview, the administrator confirmed that no such notice was provided because the facility discharged the resident to the hospital, and a bed-hold was not in effect. The resident in question had a court-appointed legal guardian and was diagnosed with obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The resident's medical record indicated that they were transferred to the hospital for further evaluation after refusing care and food. Despite the facility's policy, the guardian was not informed in writing about the bed-hold policy at the time of the transfer, leading to the identified deficiency.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The Facility failed to permit Resident #1 to return following an evaluation in the emergency department (ED) when on 03/12/24, the Facility considered Resident #1 discharged at the time of the transfer. Resident #1, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. On 03/12/24, Resident #1 refused care and food, leading to a physician order for transfer to the hospital for further evaluation. However, the Facility did not permit Resident #1 to return after the hospital determined that the resident did not need to be hospitalized and did not belong in the hospital. The Facility's Discharge/Transfer Policy, revised in 10/2022, was not followed as the Facility did not meet the criteria for discharge or transfer outlined in the policy. Interviews with the Hospital Director of Regulatory Affairs, Hospital Case Manager, Hospital Social Worker, and the Guardian confirmed that the Facility refused to permit Resident #1 to return. During a virtual meeting on 03/13/24, the Facility leadership reiterated their decision not to allow Resident #1 to return, citing the resident's refusal to accept care, food, and medications. The Facility's Administrator and Director of Nursing stated that they determined the Facility could not meet Resident #1's needs, despite having admitted and cared for the resident with the same needs a week prior. The Physician involved also indicated that he did not give an order for Resident #1's discharge, further highlighting the Facility's failure to adhere to their own policies and procedures regarding resident discharge and transfer.
Failure to Develop Effective Discharge Plan for Resident with Complex Mental Health Needs
Penalty
Summary
The facility failed to develop an effective discharge plan for a resident with complex mental health needs and a court-appointed guardian. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the facility in March 2024. Despite the resident's moderate mental impairment and refusal of care, the facility did not create a discharge plan or involve the resident's guardian in the discharge process. The facility's policy required a physician's order for non-emergent discharges, but this was not followed in this case. On March 12, 2024, the unit manager decided to transfer the resident to a hospital due to the resident's refusal to eat, take medication, and maintain hygiene. The physician provided an order for the transfer to the emergency department for further evaluation. However, the facility did not inform the guardian of the transfer in a timely manner and did not honor the guardian's request to transfer the resident to the closest hospital. Instead, the resident was sent to a hospital 60 miles away, and the facility informed the hospital that the resident could not return to the facility. The hospital staff reported that they were not prepared for the resident's arrival and that the resident did not need hospitalization. The facility did not develop a post-discharge plan of care for the resident, nor did they obtain a physician's order for discharge, as required. The facility's leadership admitted that they did not create a discharge plan because they believed the resident could return to the referring hospital if the admission was unsuccessful.
Failure to Complete Discharge Summary
Penalty
Summary
The Facility failed to ensure completion of a discharge summary for a resident who was transferred to the hospital. The resident, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's mental status was moderately impaired, and they refused care daily. On the day of the incident, the resident was reported to be out of control, not caring for themselves, not eating, agitated, uncooperative, not accepting medication, and defecating in their room. The physician was contacted and gave an order to transfer the resident to the emergency department for further evaluation, but did not give an order for discharge. The Facility's discharge note, provided to the surveyor, lacked documentation of a recapitulation of the resident's stay, course of illness/treatment or therapy, a final summary of the resident's status, or a post-discharge plan of care developed with the participation of the resident and their guardian. This failure to provide a complete discharge summary is a violation of the Facility's Discharge/Transfer Process Policy, which requires a physician order for discharge in non-emergent cases and a comprehensive discharge summary for the resident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident with severe Obsessive Compulsive Disorder (OCD) received appropriate behavioral health services to address and meet their mental health needs. The resident, who had diagnoses including OCD, delusional disorder, and unspecified psychosis, was admitted to the facility with a history of severe OCD behaviors such as refusing to use bathrooms, hoarding tendencies, and severe malnutrition due to food aversion. Despite the facility's policies and procedures indicating that residents with psychiatric disorders should receive appropriate treatment and services, the resident did not receive timely psychiatric consultation or intervention during their stay. The resident's medical record indicated multiple refusals of care, including medication, vital signs assessment, and meal trays, preferring prepackaged kosher foods instead. The resident also exhibited behaviors such as excessive handwashing, wearing gloves outside their room, and refusing to allow staff to clean their room or change bed linens. Interviews with facility staff revealed that the resident consistently refused care and requested specific accommodations related to their OCD, which were not adequately addressed by the facility. Despite the facility's awareness of the resident's severe OCD and the need for psychiatric services, the referral to the psychiatric service was delayed until the day before the resident was discharged to the hospital emergency department. The psychiatric service providers confirmed that they were not contacted about the resident during their stay, and the facility's Licensed Social Work Associate acknowledged that the referral was not sent sooner. This delay in providing necessary behavioral health services contributed to the resident's continued distress and unmet mental health needs during their time at the facility.
Improper Documentation by Social Worker
Penalty
Summary
The Facility failed to maintain compliance with regulation 258 CMR 20.00 relating to Professional Standards for social workers. Between 3/06/24 and 3/12/24, a Licensed Social Work Associate (LSWA) documented four Progress Notes in a resident's electronic health record (EHR) using the name and credentials of a Licensed Independent Certified Social Worker (LICSW). The LSWA and LICSW were both employed by a Social Work Staffing Agency contracted by the Facility, with the LSWA assigned to provide social services and the LICSW assigned to provide weekly supervision to the LSWA. The Facility's Charting and Documentation Policy requires that all services provided to residents be documented with the signature and title of the individual documenting, which was not followed in this case. The resident involved was admitted to the Facility in March 2024 with diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The LSWA admitted to providing the services described in the Progress Notes but used the LICSW's username and password to document them. The Chief Executive Officer of the Social Work Staffing Agency confirmed that the LICSW had not worked in the Facility during the resident's stay and could not have provided the services documented. The Facility Administrator was unaware of this improper documentation practice until it was brought to her attention during the investigation.
Inaccurate Documentation of Social Services
Penalty
Summary
The Facility failed to maintain accurate and complete medical records for a resident when documentation for social services was signed under another contracted staff member's name and professional credentials. Specifically, a Licensed Social Work Associate (LSWA) documented services provided to a resident using the username and password of a Licensed Independent Certified Social Worker (LICSW) who had not worked in the Facility during the resident's stay. This discrepancy was discovered during interviews and a review of the resident's electronic health record (EHR). The resident involved had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The LSWA admitted to documenting the services in the EHR under the LICSW's credentials, which was confirmed by the Chief Executive Officer of the Social Work Staffing Agency. The Facility's Administrator was unaware of this practice until it was brought to her attention during the investigation.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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