Agawam South Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Agawam, Massachusetts.
- Location
- 65 Cooper Street, Agawam, Massachusetts 01001
- CMS Provider Number
- 225176
- Inspections on file
- 18
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Agawam South Rehab And Nursing during CMS and state inspections, most recent first.
A resident at risk for malnutrition developed a pressure injury and experienced significant weight loss due to the facility's failure to promptly notify the RD and implement nutritional interventions. Staff did not consistently monitor or report weight changes, and the RD was not made aware of the resident's condition until weeks after the issues began, resulting in delayed support for wound healing and nutritional needs.
A resident with wounds, significant weight loss, and ADL needs did not have complete and accurate medical records due to missing weekly wound logs, incomplete skin assessments, and blank entries in both the TAR and CNA flow sheets. Nursing and CNA staff confirmed that required documentation was not consistently completed or reviewed, resulting in gaps in the resident's official care record.
A resident with a history of end-stage renal disease, type II diabetes, and hypertension experienced significant medication errors when Midodrine was administered despite physician orders to hold the medication if systolic blood pressure exceeded 130 mmHg. The medication was given on multiple occasions when the resident's blood pressure was above the specified threshold, as confirmed by the MAR and nursing staff interviews.
The facility failed to adhere to infection control standards, risking the transmission of infections among residents. Staff did not use PPE as required for residents on contact precautions, and wound care supplies were improperly handled. Additionally, enhanced barrier precautions were not maintained for a resident with a feeding tube and colostomy, indicating systemic issues in infection control practices.
A resident's wheelchair was repeatedly observed with dirt, debris, and food particles, indicating a failure to maintain a clean and homelike environment. The Director of Housekeeping admitted to not following the cleaning schedule and lacking a tracking system for wheelchair maintenance.
A facility failed to notify the state mental health authority for a resident review after a resident was diagnosed with Bipolar Disorder, despite policy requirements for a Level II PASRR referral. The resident, admitted with Chronic Respiratory Failure and Obstructive Sleep Apnea, was cognitively intact but had not been evaluated by a Level II PASRR. The Social Worker confirmed that a Change of Condition should have been submitted but was not.
The facility failed to create baseline care plans within 48 hours for two residents, one with MRSA and another with ESRD and DM II. This led to delays in implementing necessary precautions and providing care instructions. The Infection Preventionist and Unit Manager acknowledged the lapses in timely care planning.
A resident with a PICC line for antibiotic administration did not have the required measurements of external catheter length and arm circumference documented, as per physician orders and facility policy. This oversight was identified through a survey, which revealed no evidence of these measurements being taken since admission, despite the potential risks of catheter migration and other complications. Nursing staff confirmed the lack of documentation, and the resident could not recall the measurements being obtained.
A resident with multiple health conditions, including dementia and apraxia, did not receive consistent assistance with oral hygiene, leading to plaque buildup and odor. Despite being dependent on staff for daily living activities, the resident's oral care was neglected, with CNAs failing to provide necessary support or setup. The DON confirmed that oral care should be routine, highlighting a lapse in adherence to facility policies.
A facility failed to provide appropriate respiratory care for a resident requiring CPAP therapy due to missing physician orders after a hospital transfer. The resident, who needed assistance with the CPAP machine, did not receive consistent help from staff, leading to infrequent use. Observations showed improper storage of CPAP equipment, and interviews confirmed the omission of CPAP orders during re-admission.
A facility failed to act on a Consultant Pharmacist's recommendation for a resident on Atorvastatin, missing a fasting lipid panel to monitor cholesterol levels. The MRR was marked as agreed but was unsigned and undated, with no follow-up action taken. The DON was responsible for overseeing pharmacy recommendations but could not confirm who marked the MRR.
A medication pass error rate of 5.71% was observed when a resident received two medications late. The resident, with conditions including cerebral infarction and vascular dementia, was administered Gabapentin and Benztropine Mesylate via G-tube one hour and 41 minutes past the scheduled time. Nurse #7 cited a system problem due to workload and scheduling as the cause of the delay.
The facility failed to obtain physician-ordered lab tests for two residents, leading to a deficiency in care. One resident did not have their valproic acid levels monitored as required, while another did not receive routine tests for blood glucose, thyroid hormones, and lipids. The Director of Nursing acknowledged systemic issues and accidental discontinuation of lab orders, highlighting a gap in the facility's processes.
A resident on hospice care with COPD and GERD did not receive the correct food items as per their dietary plan, leading to unmet nutritional needs. Despite protocols for checking meal trays, the resident's meal tickets were not followed, resulting in missing items like an apple cinnamon muffin, potato wedges, and ice cream. Staff interviews revealed a lapse in the process, with the Dietary Aide responsible for ensuring correct tray contents.
Failure to Timely Notify Dietitian and Implement Nutritional Interventions for Resident with Weight Loss and Pressure Injury
Penalty
Summary
A resident with diagnoses including Parkinson's disease and bacteremia was admitted to the facility and assessed by the Registered Dietitian (RD) as being at risk for malnutrition. Despite this, the resident developed a pressure injury and experienced a significant, unplanned weight loss over a short period. The facility's policies required prompt notification of the RD and initiation of nutritional interventions for residents at risk of skin breakdown or with significant weight changes, but these steps were not taken in a timely manner. Family members reported that the resident did not receive adequate assistance with eating, leading to further weight loss. Documentation showed that the resident's weight dropped from 168 lbs. to 145.6 lbs. in just over a month, representing a 13.3% loss. Although the resident's diet was modified by therapy staff and the resident was able to eat independently, there was no evidence that the RD was notified of the severe weight loss or the development of the pressure injury until several weeks after these issues were identified. Nursing staff and unit managers confirmed that weight monitoring and reporting processes were not consistently followed, and the RD relied on nursing staff for notifications rather than proactively reviewing weight reports. Interviews with facility staff revealed that significant weight changes were not promptly communicated to the RD, and the required progress notes and notifications were not completed. The RD only became aware of the resident's condition and initiated appropriate nutritional interventions weeks after the onset of the pressure injury and significant weight loss. This delay in notification and intervention contributed to the resident not receiving timely nutritional support to address their health needs.
Incomplete Medical Record Documentation for Wound Care and ADLs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required wound treatments, had significant weight loss, and needed assistance with activities of daily living (ADLs). Nursing staff did not consistently complete required weekly wound logs and weekly nursing skin review assessments in the electronic health record (EHR) as mandated by facility policy. Specifically, there were missing entries for the weekly nursing skin review and several weekly wound logs, with staff interviews confirming that these assessments were not documented in the EHR, even though some information was recorded on paper forms that were not considered part of the official medical record. Further deficiencies were identified in the documentation of wound care treatments on the Treatment Administration Record (TAR). Several wound treatments were left unsigned on multiple dates and shifts, resulting in blank spaces on the TAR. Nursing progress notes indicated that some treatments were not administered because the resident was out of bed, but the documentation was vague and did not clarify whether treatments were re-attempted or if education was provided to the resident. Staff interviews confirmed that the lack of documentation meant it was unclear if the treatments were performed as required. Additionally, the Certified Nurse Aide (CNA) ADL flow sheets for several months contained numerous blank entries for essential care tasks such as oral hygiene, nutrition (fluid intake), and nutrition (amount eaten). CNAs and nursing staff acknowledged that documentation was expected to be completed by the end of each shift and that blank spaces indicated the required documentation was not done. The expectation was for floor nurses to review CNA documentation at the end of each shift, but this oversight did not occur, resulting in incomplete records for the resident's daily care.
Failure to Adhere to Physician's Orders for Midodrine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine, a medication used to treat orthostatic hypotension. The physician's orders clearly stated that the medication should be held if the resident's systolic blood pressure (SBP) was above 130 mmHg. However, the Medication Administration Record (MAR) for November 2024 indicated that the medication was administered on five occasions when the resident's SBP exceeded the specified threshold. The resident involved had a medical history that included end-stage renal disease, type II diabetes mellitus, and hypertension, and was dependent on renal dialysis. Despite the clear physician's orders, the medication was not held on the dates when the SBP was recorded as 141, 138, 145, 134, and 143 mmHg. Interviews with the nursing staff confirmed that the medication should have been withheld according to the physician's parameters, but it was not, leading to a significant medication error.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards, leading to potential transmission of communicable diseases and infections among residents. Specifically, the facility did not ensure that wound care supplies used inside a resident's room were not removed and stored in the clean utility room, which could lead to contamination. During wound care for a resident with MRSA, a nurse used contaminated scissors to cut clean dressing materials without disinfecting them, risking cross-contamination of the wound. Staff also failed to wear necessary PPE to maintain contact isolation precautions for residents with communicable infections. For instance, a rehabilitation staff member and maintenance staff entered a resident's room, who was on contact precautions, without donning a gown and gloves. Similarly, a nurse entered the same resident's room without PPE, allowing her clothing to come into contact with potentially contaminated surfaces. Additionally, the facility did not maintain enhanced barrier precautions for a resident with a feeding tube and colostomy. Staff members entered the resident's room and provided care without wearing gowns, despite the requirement for PPE during high-contact activities. This lack of adherence to infection control protocols was observed across multiple staff members and residents, indicating a systemic issue within the facility.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, specifically regarding the cleanliness of the resident's wheelchair. The resident was observed multiple times over several days with a wheelchair that had dirt, debris, and food particles on the chair cushion, frame, brakes, and wheels. These observations were made on three separate occasions, indicating a persistent issue with the cleanliness of the wheelchair. During an interview, the Director of Housekeeping acknowledged the failure to adhere to the wheelchair cleaning schedule, which was supposed to occur twice a month. The Director admitted that there was no tracking system in place to verify which wheelchairs had been cleaned. Despite the schedule indicating that the wheelchairs on the resident's unit were due for cleaning, the resident's wheelchair remained unclean. The Director of Housekeeping confirmed that the wheelchair should not have been in such a condition and needed cleaning, but could not specify when it was last cleaned.
Failure to Notify State Mental Health Authority After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one resident. Specifically, the facility did not request a Preadmission Screening and Resident Review Level II screen (PASRR) after the resident was diagnosed with Bipolar Disorder and experienced limitations in major life activities due to mental illness. The facility's policy required prompt referral to the state mental health or intellectual authority for a Level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The resident was admitted with diagnoses including Chronic Respiratory Failure and Obstructive Sleep Apnea. The Minimum Data Set assessment indicated the resident was cognitively intact and had not been evaluated by a Level II PASRR, despite having active diagnoses of Depression and Bipolar Disorder. The resident's PASRR Level I screen showed no diagnosis of mental illness or treatment history, and a negative SMI screen. A Behavioral Health Group Note later confirmed the diagnosis of Bipolar Disorder and a history of Depression and Anxiety. The Social Worker acknowledged that a Change of Condition should have been submitted through the Massachusetts Executive Office of Health and Human Services portal, but it was not done.
Failure to Create Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in their care. One resident, who was admitted with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) in a wound, did not have a baseline care plan created until eight days after admission. This delay resulted in the absence of necessary contact precautions for six days, despite the resident's condition requiring such measures to prevent the spread of infection. The Infection Preventionist confirmed that a baseline care plan should have been established within 72 hours, and a physician's order for contact precautions should have been in place upon admission. Another resident, admitted with End Stage Renal Disease and Type 2 Diabetes, also did not have a baseline care plan completed within the required 48-hour timeframe. The plan was completed four days after admission, and a copy was not provided to the resident. The Unit Manager acknowledged that the baseline care plan should be completed within 48 hours and reviewed with the resident, although a copy was not given. These oversights indicate a failure to meet the immediate care needs of the residents upon their admission to the facility.
Failure to Measure and Document PICC Line Measurements
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The deficiency was identified through observation, interview, and record review, revealing that the facility did not measure the external catheter length and arm circumference as ordered by the physician. This oversight increased the potential risk of complications such as infiltration, migration, and deep vein thrombosis. The resident was admitted with diagnoses including cellulitis and Methicillin-Resistant Staphylococcus Aureus (MRSA) and had a PICC line inserted for intravenous administration of antibiotics. The facility's policy required measuring the length of the lumen and the circumference of the upper arm upon admission, with each dressing change, and as needed. However, there was no documented evidence of these measurements being taken since the resident's admission, despite physician orders specifying these requirements. During the survey, it was observed that the PICC line dressing was in place, but the necessary measurements had not been recorded. Interviews with nursing staff confirmed the lack of documentation and the importance of these measurements to ensure the PICC line had not migrated. The resident also could not recall staff obtaining these measurements since admission, highlighting the facility's failure to adhere to its own policies and physician orders.
Failure to Provide Adequate Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance for a resident, identified as Resident #45, in performing activities of daily living, specifically oral hygiene. Resident #45, who was admitted in November 2019, has multiple diagnoses including epilepsy, dementia, adult failure to thrive, apraxia, aphasia, and weakness, which render them dependent on assistance for daily activities. The facility's policy mandates that residents unable to perform ADLs independently should receive appropriate care to maintain personal hygiene, including oral care. However, the review of the resident's care plan and task flow sheets indicated inconsistencies in providing oral hygiene care, with several instances where the resident did not participate in oral hygiene care or was not assisted as required. Observations and interviews conducted by the surveyor revealed that Resident #45 had a significant buildup of plaque and debris on their teeth, and a strong odor was noted from their mouth, indicating a lack of regular oral hygiene. During an observation, a CNA was unable to locate a toothbrush and toothpaste in the resident's room, suggesting a lack of preparedness and oversight in ensuring the resident's oral hygiene needs were met. The CNA eventually provided the necessary items, and the resident was able to brush their teeth independently, demonstrating that with proper setup, the resident could participate in their oral care. Further interviews with CNAs revealed a lack of consistent oral care provision, with one CNA admitting to not providing morning mouth care due to concerns about the resident's bleeding gums. This CNA opted to use a toothette instead of a toothbrush, which was not in line with the facility's standard practice as stated by the Director of Nursing. The DON confirmed that mouth care should be provided every morning and night, and was unaware of any specific dental issues with the resident that would necessitate deviation from standard care practices.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The deficiency was identified when it was discovered that there was no physician's order for the CPAP machine, which is necessary for residents with conditions such as chronic respiratory failure and obstructive sleep apnea. The resident, who was cognitively intact, expressed a need for assistance in using the CPAP machine at night but reported that the staff did not consistently offer help, leading to infrequent use of the device. The resident had been admitted to the facility with a care plan that included the use of continuous oxygen and CPAP therapy. However, after a hospital transfer, the CPAP orders were not re-entered into the electronic medical record upon the resident's return. This oversight resulted in the resident not receiving the prescribed CPAP therapy, as there was no documentation of its use in the Medication Administration Record or Treatment Administration Record for several months. Observations by the surveyor revealed that the CPAP machine and its components were not stored properly, with the mask and tubing left undated and unbagged, increasing the risk of contamination. Interviews with the nursing staff and unit manager confirmed that the omission of the CPAP orders was an error during the re-admission process, and the resident had not been offered the CPAP therapy as required since returning from the hospital.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action on a Medication Regimen Review (MRR) recommendation for a resident who was receiving Atorvastatin, a cholesterol-lowering medication. The Consultant Pharmacist recommended a fasting lipid panel to monitor the resident's cholesterol levels, but there was no documented evidence that this test was conducted. The MRR, dated 4/18/24, was found to be unsigned and undated, with only a handwritten 'x' indicating agreement, but no follow-up action was taken. The resident involved had a medical history including hypertension and hemiparesis due to a cerebrovascular accident. The Director of Nursing (DON) was responsible for overseeing pharmacy recommendations and acknowledged the lack of follow-through on the MRR. The process involved sending recommendations to the DON's email, printing them, and giving them to the provider for review. However, the lipid panel was not drawn, and the DON was unsure who marked the MRR as agreed, suspecting it might have been the Nurse Practitioner.
Medication Pass Error Rate Exceeds Limit
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than five percent, resulting in a medication error rate of 5.71%. This deficiency was observed when a resident was administered two scheduled medications later than the allowed timeframe. The resident, who was admitted to the facility with diagnoses including cerebral infarction, vascular dementia, and gastrostomy, was supposed to receive Gabapentin and Benztropine Mesylate via G-tube at specific times. However, these medications were administered one hour and 41 minutes past the scheduled time. The error occurred during a medication pass on the D-Wing unit, where Nurse #7 was responsible for administering medications. Nurse #7 acknowledged the late administration and attributed it to a system problem, explaining that she was scheduled to work on a different wing earlier in the day and had to manage medications for 17 residents before moving to the D-Wing. The Director of Nursing confirmed that the resident should not have received the medications late, indicating a lapse in the facility's medication administration process.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered by the physician for two residents, leading to a deficiency in care. Resident #28, who was admitted with diagnoses including Vascular Dementia, Bipolar Disorder, and Major Depressive Disorder, had a physician's order for routine monitoring of valproic acid levels, a medication used for managing seizures and behaviors. Despite the order being in place since June 2023, the facility did not document any evidence of the valproic acid level being drawn since December 2023. This oversight was confirmed by the Unit Manager and the Director of Nursing, who acknowledged a systemic issue in obtaining routine lab work. Resident #52, diagnosed with Type 2 Diabetes, Hyperlipidemia, and Hypothyroidism, also experienced a lapse in routine lab work. The resident's physician had ordered regular monitoring of blood glucose levels, thyroid hormone levels, and lipid panels. However, there was no documented evidence of these tests being conducted since February 2024. The resident, who was cognitively intact, was unaware of the specific lab work being monitored. The Director of Nursing identified that the routine lab work had been accidentally discontinued and not renewed, resulting in the deficiency. The facility's policy on diagnostic services, revised in October 2024, mandates that diagnostic tests be provided and reported as required by the physician. However, the failure to adhere to this policy for Residents #28 and #52 highlights a significant gap in the facility's processes for managing and executing physician-ordered lab work. The Director of Nursing acknowledged the need for education among the nursing staff regarding the review and renewal of monthly laboratory sheets to prevent such deficiencies in the future.
Failure to Follow Dietary Plan for Resident
Penalty
Summary
The facility failed to follow the dietary plan as recommended by the Registered Dietitian (RD) for a resident, leading to unmet nutritional needs and preferences. The resident, who was on hospice care and had conditions such as Chronic Obstructive Pulmonary Disease (COPD) and Gastro-Esophageal Reflux Disease (GERD), was supposed to receive a regular diet with specific items for comfort and pleasure, including ice cream. However, during multiple meal observations, the resident did not receive the items listed on their meal tickets, such as an apple cinnamon muffin, potato wedges, and ice cream. The resident expressed dissatisfaction with the missing items and noted that complaints to the kitchen had not resulted in changes. Interviews with staff revealed that a nurse was responsible for checking meal trays to ensure they matched the meal tickets before distribution. Despite this protocol, discrepancies were observed, and the Food Service Director acknowledged that the resident should have received the items listed on the meal tickets. The Dietary Aide responsible for loading the meal trays was identified as the person accountable for ensuring the correct items were included, indicating a lapse in the facility's process for meal preparation and delivery.
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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