Adviniacare At Provincetown
Inspection history, citations, penalties and survey trends for this long-term care facility in Provincetown, Massachusetts.
- Location
- 100 Alden Street, Provincetown, Massachusetts 02657
- CMS Provider Number
- 225637
- Inspections on file
- 14
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Adviniacare At Provincetown during CMS and state inspections, most recent first.
Three residents in the facility were found with inaccessible call bell devices, which were either wrapped around bed rails or hanging towards the floor, making them out of reach. These residents, with varying degrees of cognitive impairment and other medical conditions, were unable to use the call bells to call for assistance. Observations confirmed the inaccessibility of the call bells, and the Director of Nursing acknowledged the issue.
The facility failed to address grievances from Resident Council Meetings over several months. Residents reported long call bell wait times, leading to distressing situations, but these concerns were not documented or resolved. The Activity Director did not complete grievance forms, and the Administrator misunderstood what constituted a grievance, resulting in unresolved issues.
The facility failed to secure residents' PHI on a nursing unit, as surveyors observed unattended medication carts with open computers displaying sensitive information. In one instance, a computer outside the dining room showed residents' names and photos, visible to others nearby. Another incident involved a computer in the hallway displaying a resident's name and medication list. Nurses acknowledged the need to close screens to protect privacy.
A resident with severe cognitive impairment and a history of falls experienced six unwitnessed falls due to inadequate supervision and ineffective interventions. The facility's fall prevention policies were not consistently implemented, with incomplete evaluations and lack of root cause analysis. Staff interviews revealed failures in documentation and response to falls, contributing to ongoing risks.
The facility failed to maintain sufficient staffing levels, particularly on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. This led to delayed responses to call bell devices, impacting residents' well-being. Interviews and Resident Council minutes highlighted ongoing issues with staffing shortages and long wait times for call bell responses, especially during evening and night shifts.
The facility failed to monitor medication refrigerator temperatures properly, with temperatures recorded only once daily and several instances of out-of-range temperatures. Additionally, medication carts were left unlocked and unattended, posing a security risk. Staff interviews revealed confusion about responsibilities for temperature monitoring and cart security. The DON acknowledged the need for twice-daily temperature checks and locked carts when unattended.
Surveyors found that the facility failed to follow food safety standards, with improperly labeled, dated, and stored food in the kitchen's refrigerator and freezer. Items like hard-boiled eggs, muffins, and deli meats were undated and unlabeled, while some were left open to air. The Food Service Manager confirmed that such practices are against the facility's protocols, which require proper labeling and discarding of food not in original packaging after 48 hours.
A facility failed to accurately document fluid intake for a resident with a 1200 ml/day fluid restriction. The resident's MAR did not reflect correct fluid amounts per shift or 24-hour totals. Staff interviews revealed inconsistencies in documentation practices, with CNAs verbally reporting intake to nurses without a formal recording system. The DON acknowledged the lack of a system to ensure accurate tracking of the resident's fluid intake.
The facility failed to reassess bed safety for two residents with limited mobility when specialty mattresses were introduced, leading to potential entrapment risks. The Maintenance Director conducted annual checks but was unaware of the need for reassessment with new mattresses, resulting in 10 out of 36 beds not being evaluated for safety.
A facility failed to provide a resident and their representative with a summary of the baseline care plan within 48 hours of admission, as required by policy. The resident, admitted with multiple diagnoses, was confused and unable to be interviewed. The family member was uncertain about the care plan, and the baseline care plan document lacked signatures, indicating it had not been reviewed with them. Interviews confirmed the oversight, and the facility's policy was not followed.
The facility failed to obtain a physician's order for Hospice services for a resident and did not transcribe handwritten medication orders into the electronic medical record for another resident. Additionally, the facility did not conduct required neurological checks after unwitnessed falls. The deficiencies involved residents with Parkinson's disease and severe cognitive impairment.
A resident with severe cognitive impairment and a history of falls was moved by two CNAs from the floor to a Broda chair without a nurse's assessment, contrary to the facility's Fall Prevention and Management policy. The incident report lacked staff statements, and the DON was unaware of the CNAs involved. Nurse #6 confirmed the CNAs moved the resident without prior assessment.
A resident with COPD and chronic respiratory failure did not receive proper respiratory equipment care. The nebulizer tubing and mouthpiece were not stored correctly, and the oxygen concentrator was dusty with an unclean filter. Staff interviews revealed confusion over cleaning responsibilities, with the DON confirming a lack of documentation for equipment maintenance.
The facility failed to conduct necessary side rail risk assessments for three residents, including those with Parkinson's and Alzheimer's disease. Initial assessments were not performed upon admission or when new mattresses were introduced, and appropriate alternatives were not attempted before installing side rails. The lack of documentation was confirmed by the DON and a nurse.
The facility failed to address pharmacy consultant recommendations for three residents, including clarifying medication orders and reassessing medication needs. A resident's duplicate Guaifenesin orders were not clarified, another resident's bowel medication orders lacked clarification, and a third resident's need for Protonix and thyroid lab work was not reassessed. The DON acknowledged the lack of documentation and action on these recommendations.
A resident with thrombophlebitis was prescribed Eliquis, an anticoagulant, but the facility failed to monitor for signs of bleeding as required. Although the medication was administered correctly, the monitoring order was not documented in the MAR or TAR, preventing staff from tracking potential side effects. The DON confirmed the oversight, acknowledging the inability to assess the resident's condition accurately.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that three residents had their call bell devices accessible and within reach while in their beds, as observed by surveyors. Resident #4, who was admitted in December 2020 with diagnoses including unspecified dementia and overactive bladder, was found with the call bell device wrapped around the left upper side rail and hanging down toward the floor, making it inaccessible. The resident expressed unawareness of the call bell's location and was unable to use it to call for assistance. Resident #27, admitted in January 2021 with severe cognitive impairment and other diagnoses, also had an inaccessible call bell. The device was wrapped around the right upper side rail and the push button was underneath the mattress, out of reach. The resident was unable to locate the call bell and expressed an inability to call for help. Observations confirmed the call bell's inaccessibility on multiple occasions. Resident #12, admitted in March 2016 with Parkinson's disease and dementia, was observed with the call bell cord wrapped around the upper side rail and hanging down towards the floor, out of reach. Despite being fed by a CNA who had a beeper for call light alerts, the resident's call bell remained inaccessible. The Director of Nursing acknowledged that all residents should have call bell devices within reach, but this was not the case for the residents involved.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and promptly resolve grievances brought forward during Resident Council Meetings held from March 2024 through January 2025. The facility's policy required that concerns raised during these meetings be recorded in minutes and followed with a concern/response form filled out by the designated staff representative. These forms were to be addressed to the corresponding Department Head to provide a resolution within seven days. However, the review of the grievance book indicated that concerns documented during the Resident Council meetings were not documented on a grievance/complaint/concern form, and no follow-up or resolution was provided for the issues raised. During interviews, residents expressed ongoing issues with long call bell wait times, particularly during the evening and night shifts, which had not been resolved. Residents reported waiting 15 minutes or longer for assistance, leading to situations where they soiled themselves due to the delay. Despite these concerns being repeatedly raised in Resident Council meetings, residents did not receive any follow-up or discussion about the issues until the next monthly meeting. The Activity Director, responsible for organizing the meetings, admitted to not completing grievance forms for issues raised, as she did not consider them grievances. The Administrator, identified as the Grievance Official, confirmed that only one grievance was filed in the grievance book for the period in question. She did not consider the residents' complaints to rise to the level of a grievance, as she believed a grievance required an outcome associated with it. This misunderstanding of what constitutes a grievance contributed to the facility's failure to address and resolve the residents' concerns, as documented in the Resident Council Minutes.
Failure to Secure Residents' Protected Health Information
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' protected health information (PHI) on one nursing unit. On two separate occasions, surveyors observed unattended medication carts with open computers displaying sensitive resident information. The first incident occurred outside the main dining room, where a computer on a medication cart was left open, showing various residents' names, photos, and identifying information. This information was visible to residents, a visitor, and a dietary aide in the vicinity. Nurse #3 acknowledged that she should have closed the computer screen to maintain privacy. The second incident was observed in the unit hallway, where another unattended medication cart had an open computer displaying a resident's name and medication list. This information was visible to a consultant mobile imaging provider and a non-clinical staff member. Nurse #5 admitted responsibility for the cart and recognized the need to close the computer screen to protect the resident's private health information. The Director of Nursing confirmed that nursing staff should log out or close computer screens when carts are unattended to safeguard residents' PHI.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and effective interventions to prevent avoidable accidents, specifically for a resident with a history of falls. The resident, who was admitted in October 2024, had severe cognitive impairment and was dependent on staff for transfers and toileting. Despite being identified as a major fall risk, the initial Fall Risk Evaluation was incomplete and unsigned, lacking a fall risk score to guide care plan development. The resident experienced six unwitnessed falls from October 2024 to February 2025, indicating a lack of effective fall prevention measures. The facility's policies on Fall Prevention and Management and Accidents and Incidents were not consistently implemented. After each fall, the investigations often lacked a root cause analysis and staff statements, and new interventions were either not added or were ineffective. For instance, after a fall on 10/24/24, a fall mat was provided, but this intervention was only added to the care plan six days later. Similarly, after a fall on 11/9/24, no new interventions were added to the care plan, despite the existing interventions being ineffective. Interviews with staff revealed further deficiencies in documentation and response to falls. A fall on 1/7/25 was not documented in the medical record, and there was no incident report available. Staff interviews indicated that the fall occurred when a CNA left the resident on the toilet to attend to another resident who was screaming for help. The nurse on duty did not respond to the screaming resident, and the fall was not documented because the nurse wanted to consult with the DON on how to document it without making it sound severe. This lack of documentation and failure to implement effective interventions contributed to the ongoing risk of falls for the resident.
Staffing Deficiencies and Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The report indicated excessively low weekend staffing without any nurse staffing waivers in place. The facility's staffing plan outlined a minimum requirement of licensed nurses and certified nursing assistants (CNAs) for each shift, but the actual staffing levels frequently fell short of these requirements. Interviews with the Administrator and Director of Nursing (DON) revealed that staffing was based on census rather than hours per patient day (HPPD), and there were challenges with geographical location and travel, leading to reliance on a single agency for staffing, which was not consistently utilized. The deficiency was further highlighted by the facility's inability to respond to call bell devices in a timely manner, as voiced by residents and documented in Resident Council minutes. Residents reported long wait times for call bell responses, sometimes resulting in soiling themselves due to delays. Interviews with staff and residents indicated that staffing shortages were more pronounced during the summer and on weekends, with frequent call-outs exacerbating the issue. Despite efforts to adjust staffing based on census, the facility consistently failed to meet the minimum staffing requirements, impacting the residents' ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The Resident Council minutes from various months in 2024 consistently documented grievances regarding call bell response times, with residents expressing concerns about the lack of timely responses, especially during evening and night shifts. The Activity Director acknowledged that education and audits of call bell response times did not begin until January 2025, several months after the grievances were initially raised. This delay in addressing the concerns contributed to the ongoing issues with staffing and resident care, as the facility struggled to maintain adequate staffing levels and respond promptly to residents' needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly monitor and record the temperatures of a medication refrigerator, which is crucial for maintaining the integrity of stored medications and vaccines. The refrigerator was observed with a temperature of 55 degrees Fahrenheit, which is outside the recommended range of 36 to 46 degrees Fahrenheit. The temperature log showed that temperatures were only recorded once daily, and there were several days with no recorded temperatures or temperatures that were out of range. Staff interviews revealed a lack of clarity on who was responsible for monitoring and recording the temperatures, and there was confusion about how to retrieve temperature data from the monitoring device. Additionally, the facility did not ensure that medication carts were locked when not under the direct supervision of a licensed nurse. On two separate occasions, medication carts were observed unlocked and unattended in areas accessible to residents and visitors. In one instance, a nurse admitted to leaving the cart unlocked while away from the area. In another instance, a medication cart was left unlocked in a hallway, out of sight of the nursing desk, while a nurse was at the desk and a CNA was occupied elsewhere. The Director of Nursing acknowledged that medication refrigerator temperatures should be checked twice daily and that medication carts must be locked when unattended. However, there was a lack of proper procedures and accountability in place to ensure these practices were consistently followed, leading to potential risks to the safety and efficacy of medications and vaccines stored in the facility.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as observed by surveyors during an inspection of the main kitchen's cook's refrigerator and walk-in freezer. The inspection revealed multiple instances of improperly labeled, dated, and stored food items. Specifically, the cook's refrigerator contained undated and unlabeled peeled hard-boiled eggs, muffins, and sliced deli meats. Additionally, some food items, such as raw hamburger patties and cooked elbow pasta, were either improperly dated or left open to air, compromising their safety. The walk-in freezer also contained unsecured and open bags of corn kernels and carrot slices, exposing them to potential environmental contaminants. During an interview, the Food Service Manager acknowledged that all food stored in the refrigerator and freezer should be labeled, dated, and properly stored to ensure food safety. The manager stated that food not in its original packaging should be discarded after 48 hours, and any improperly labeled, dated, or stored food should be discarded. The failure to follow these protocols poses a risk of foodborne illness to residents, who are considered high-risk individuals.
Inaccurate Documentation of Fluid Intake for Resident with Fluid Restriction
Penalty
Summary
The facility failed to maintain accurate documentation of fluid intake for a resident with a prescribed fluid restriction of 1200 milliliters per day. The resident, who had diagnoses including congestive heart failure and hyponatremia, was observed consuming fluids that were not accurately recorded in the Medication Administration Records (MAR) for March 2025. The records did not reflect the correct amounts of fluid intake for each shift or the total for a 24-hour period. The facility's policy required the nursing and dietary departments to collaborate on fluid distribution and documentation, but this was not effectively implemented. Interviews with nursing staff revealed inconsistencies in documenting fluid intake, with some nurses only recording the fluids they personally administered and not including house supplements. Certified Nursing Assistants (CNAs) reported that they verbally communicated fluid intake to nurses, but there was no designated place for them to document it. The Director of Nurses acknowledged that the current practice did not ensure accurate tracking of the resident's fluid intake, as there was no system in place to verify if the resident's daily fluid restriction was met or exceeded.
Failure to Reassess Bed Safety with Specialty Mattresses
Penalty
Summary
The facility failed to conduct a new assessment of bed, side rails, and mattresses for potential entrapment risks when the mattress was changed for two residents with limited mobility. Resident #12, who had Parkinson's disease and dementia, was observed with bilateral side rails and an air mattress set to 120 pounds. The facility's policy required checking compatibility and ensuring proper installation of bed components, but there was no reassessment after the air mattress was introduced. Similarly, Resident #15, with severe cognitive impairment and a history of falls, was found with a perimeter air mattress that was not aligned with the bed frame, creating large gaps between the mattress and the head and footboards. The Maintenance Director admitted to conducting bed entrapment checks only once a year and was unaware of the need to reassess beds when specialty mattresses were added. The last assessment was in August 2024, and it was discovered that 10 out of 36 beds with specialty mattresses had not been reassessed for entrapment risks. The Director of Nursing confirmed that these beds should have been reassessed, indicating a lapse in following the facility's policy and procedures for ensuring resident safety.
Failure to Provide Baseline Care Plan Summary to Resident and Representative
Penalty
Summary
The facility failed to provide a resident and their representative with a summary of the baseline care plan within 48 hours of admission, as required by the facility's policy. The resident, who was admitted with multiple diagnoses including repeated falls, dementia, and metabolic encephalopathy, was observed to be confused and unable to be interviewed. The resident's family member expressed uncertainty about the resident's care and mentioned that no formal meeting had occurred to discuss the care plan. The baseline care plan document lacked signatures from the resident and their representative, indicating it had not been reviewed with them. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the baseline care plan had not been provided to the resident or their representative. The DON acknowledged that a care plan meeting had not yet taken place, and the Administrator admitted that the staff should have offered the care plan summary to the resident's representative but did not. The facility's policy requires that a baseline care plan be developed and shared with the resident and their representative within 48 hours of admission, but this was not adhered to in this case.
Failure to Ensure Proper Documentation and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for two residents. For one resident, the facility did not obtain a physician's order for the provision of Hospice services. The resident, who had diagnoses including Parkinson's disease and dementia, was admitted to the facility in March 2016. Despite receiving Hospice care, there was no physician's order documented in the medical record. Interviews with the nursing staff and the Director of Nursing confirmed the absence of a physician's order for Hospice services. For another resident, the facility failed to transcribe handwritten physician's telephone orders for Carbidopa-Levodopa ER capsules into the electronic medical record. This resident, admitted in October 2024, had severe cognitive impairment and a history of falls. The handwritten orders, which included instructions to open the capsules and mix them with food or supplements, were not entered into the electronic medical record. The Director of Nursing acknowledged that the orders should have been transcribed but were not. Additionally, the facility did not conduct neurological checks after the resident sustained unwitnessed falls. The resident experienced five unwitnessed falls between October 2024 and February 2025, but neurological assessments were not conducted following three of these falls. The facility's policies required neurological checks for any unwitnessed fall, but the Director of Nursing confirmed that these assessments were not completed as required.
Failure to Follow Fall Management Policy
Penalty
Summary
The facility failed to adhere to its Fall Prevention and Management policy when a resident experienced an unwitnessed fall. The policy requires a complete head-to-toe assessment by a nurse before moving a resident who has fallen, unless there is a life-threatening safety concern. However, two CNAs moved the resident from the floor to a Broda chair without a nurse's assessment. The resident, who had severe cognitive impairment and a history of falls, was found on the floor with discoloration on the right cheek after the fall. The incident report did not include statements from the staff involved, and the Director of Nursing was unaware of which CNAs moved the resident. Interviews revealed that CNA #3 and another unidentified CNA moved the resident without waiting for a nurse's assessment. Nurse #6 confirmed witnessing the CNAs lifting the resident without prior assessment. The facility's failure to follow its policy resulted in a deficiency in promoting and managing safe nursing care.
Deficiency in Respiratory Equipment Care
Penalty
Summary
The facility failed to provide proper care and storage of respiratory equipment for a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident was observed using a nebulizer machine, but the tubing and mouthpiece were not stored in a plastic bag as required by the facility's policy, potentially exposing them to environmental contaminants. Additionally, the oxygen concentrator used by the resident was found to be covered in dust and hair, with the external rear filter also laden with dust. Interviews with staff revealed a lack of clarity regarding the responsibility for cleaning and maintaining the oxygen concentrators. Nurse #3 indicated that housekeeping was responsible for wiping down the equipment, while Housekeeper #1 stated that cleaning oxygen concentrators was not part of her duties. The Maintenance Director also confirmed that neither housekeeping nor maintenance staff were responsible for cleaning the concentrators or filters, attributing the task to nursing staff. The Director of Nursing (DON) acknowledged that the nebulizer equipment should have been stored properly and that there was no physician's order for cleaning the oxygen concentrator or its filter. The DON stated that the night shift nursing staff was responsible for monitoring and cleaning the equipment weekly, but there was no documentation to confirm that these tasks were being performed. This lack of documentation and clarity in responsibilities contributed to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Conduct Side Rail Risk Assessments
Penalty
Summary
The facility failed to conduct necessary assessments for the risk of entrapment with the use of side rails for three residents. For Resident #12, who was admitted in March 2016 with diagnoses including Parkinson's disease and dementia, the facility did not perform an initial side rail assessment upon admission or when the resident received an air overlay pressure reducing mattress. This oversight meant there was no evaluation to ensure the resident was not at risk of entrapment and that the bed's dimensions were suitable for the resident's size and weight. Resident #15, admitted in October 2024 with Parkinson's disease and severe cognitive impairment, also did not receive an initial side rail assessment. Additionally, the facility did not attempt appropriate alternatives before installing the side rails, nor did they conduct an assessment when the resident received a perimeter air mattress. The medical record lacked documentation of these assessments, and the Director of Nursing confirmed the absence of such records. For Resident #33, admitted in November 2022 with Alzheimer's disease, the facility failed to attempt appropriate alternatives before installing side rails and did not conduct a quarterly bed rail assessment. The last recorded side rail assessment was in October 2023, and no subsequent assessments were found. Nurse #1 confirmed the lack of documentation for side rail assessments following the October 2023 assessment.
Failure to Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed in a timely manner and maintained as part of the permanent medical record for three residents. For Resident #7, the facility did not act upon the June 2024 consultant pharmacist's recommendation to clarify the need for two as-needed Guaifenesin orders. The Director of Nursing (DON) acknowledged that there was no documentation indicating that the recommendation had been addressed, which signifies that the action was not completed. For Resident #16, the facility did not address the consultant pharmacist's recommendation for an order clarification regarding the resident's bowel medications. The recommendation was made in June 2024, but the medical record lacked evidence that the nursing staff reviewed and addressed the order clarification request. The DON confirmed that there was no documentation to show that the recommendation had been acted upon. Resident #2's medical record did not contain the consultant pharmacy recommendation dated June 5, 2024, which included suggestions for a thyroid lab and a reassessment of the ongoing need for Protonix. The Pharmacy Consultant confirmed that these recommendations were communicated to the DON, but the medical record did not reflect any review or action taken by the physician or physician extender. The DON later provided copies of the recommendations, but there was no evidence of timely action taken in response to them.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse consequences of anticoagulant medications. The resident, who was admitted in February 2018, had a diagnosis of thrombophlebitis and was prescribed Eliquis, an anticoagulant, to manage this condition. The physician's orders required monitoring for signs and symptoms of bleeding or bruising every shift while the resident was on Eliquis. However, a review of the medical records from January 2025 through March 2025 revealed that although Eliquis was administered as ordered, there was no documentation indicating that staff monitored the resident for bleeding as required. During an interview, the Director of Nursing acknowledged that the monitoring order was not included in the Medication Administration Record or Treatment Administration Record, which prevented the staff from documenting any potential side effects. This oversight meant that the facility could not determine if the resident was experiencing any adverse effects from the medication.
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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