Agawam West Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Agawam, Massachusetts.
- Location
- 61 Cooper Street, Agawam, Massachusetts 01001
- CMS Provider Number
- 225253
- Inspections on file
- 21
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Agawam West Rehab And Nursing during CMS and state inspections, most recent first.
A resident who was severely cognitively impaired and fully dependent on staff for bed mobility fell from bed and sustained a head injury requiring hospital treatment after a CNA turned away during incontinence care, leaving the resident unattended and out of reach. The bed was in its highest position at the time, and the incident resulted in a laceration and epidural hematoma.
A resident with multiple medical conditions and moderate cognitive impairment was administered quetiapine, an antipsychotic medication, without written informed consent as required by facility policy. Consent was not obtained until more than a month after the medication was started, and the consent form did not reflect the actual prescribed dosage. The DON confirmed that informed consent should have been obtained prior to administration and that the documentation was missing.
A resident with an above-the-knee amputation and a history of falls required bilateral bedrails for safe mobility, as documented in their care plan and physician orders. When one bedrail became detached, staff were aware but did not ensure timely repair or replacement. The resident subsequently fell while attempting to use the missing bedrail, resulting in a femur fracture and head injury.
A resident with a history of amputation and falls was provided bilateral bedrails without documented assessment or trial of alternatives, as required by facility policy. Staff confirmed the resident used bedrails for mobility, but there was no evidence of risk discussion or annual reassessment, and the DON acknowledged the lack of required documentation.
A resident with bipolar disorder was administered an incorrect dosage of quetiapine for multiple days after nursing staff inaccurately reconciled hospital discharge orders, resulting in the medication being given twice daily instead of once daily. The error was not identified until the resident showed signs of lethargy and unstable vital signs, revealing a failure to properly verify and clarify medication orders as required by facility policy.
Two residents who required total staff assistance for ADLs had incomplete CNA documentation in their medical records, with multiple shifts left blank over several weeks, despite facility policy requiring accurate and complete charting.
A facility failed to maintain complete and accurate medical records for a resident, with incomplete nursing documentation in the MAR and inaccuracies in the Controlled Substance Register. The MAR showed blank spaces for scheduled medications, indicating a lack of documentation for medications like Clonazepam and Oxycodone. The Controlled Substance Register was missing prescription numbers, dates, and accurate dosage directions. The resident had a history of brain disorders and anxiety, requiring medications such as Ativan, Clonazepam, and Oxycodone.
The facility failed to maintain accurate Advance Directives for three residents. Two residents had invalid MOLST forms due to missing signatures from their HCPs and physicians, despite being cognitively impaired. Another resident, deemed capable of making medical decisions, was not offered the opportunity to establish a new Advance Directive after their HCP was deactivated.
The facility failed to notify the physician of significant health changes for two residents. One resident with Diabetes Mellitus Type 2 had blood sugar levels exceeding 400 mg/dL on multiple occasions without physician notification, contrary to facility policy. Another resident experienced a significant weight loss of 10.73% in one month, but the physician was not informed, and a requested re-weight was not obtained. These deficiencies indicate a failure to follow notification protocols for significant health changes.
The facility failed to complete and transmit MDS assessments within required timeframes for four residents. Delays included a quarterly assessment transmitted 28 days late and an admission assessment completed 17 days after the ARD. MDS nurses indicated that corporate staff handle transmissions, and they lack access to do so themselves.
A facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition. The resident, with diagnoses including Bipolar Disorder and Major Depression, experienced suicidal ideation and was transferred to the hospital twice. Despite these changes, the facility did not request a PASRR Level II evaluation. The Social Worker acknowledged the oversight during an interview.
A resident with a diagnosis of hearing loss did not receive audiology services despite a request from their representative and a physician's order for ancillary care. The resident's hearing ability declined, and they were not provided with hearing aids, leading to communication difficulties. The DON confirmed that the resident should have been referred to an audiologist, indicating a failure in care coordination.
A resident, solely reliant on tube feeding, did not receive the prescribed volume of enteral nutrition due to a nurse administering only 240 ml instead of the ordered 356 ml. This discrepancy was acknowledged by the nurse, highlighting a failure to adhere to Physician's orders and placing the resident at risk for altered nutritional status.
A facility failed to maintain an oxygen concentrator filter in a clean and functional manner for a resident with asthma and acute respiratory failure. Despite physician orders for weekly cleaning, observations showed a thick coating of dust on the filter, indicating non-compliance. The Unit Manager confirmed the discrepancy between documented cleaning and the filter's condition, posing a risk to the resident's respiratory care.
A resident with quadriplegia and a signed consent for dental services was not referred for necessary dental care, despite a physician's order and facility policy requiring such services. The resident, who was cognitively intact, reported never being seen by a dentist and relied on their brother for oral hygiene assistance. The DON confirmed the oversight, acknowledging the resident should have received dental services.
The facility failed to maintain sanitary conditions in three unit kitchenettes, with observations of sticky substances in refrigerators and food debris in a microwave. Staff were unclear about cleaning responsibilities, and the A Wing kitchenette had unlabeled and undated food. The Food Service Director confirmed the lack of a cleaning schedule for these appliances.
A facility failed to document social service supportive visits for a resident with a history of suicidal ideation, despite multiple hospital evaluations. The resident, diagnosed with bipolar disorder and major depression, expressed suicidal thoughts on several occasions. Facility policies require documentation of such visits, but the social worker admitted to not recording them, leading to incomplete medical records.
A facility failed to implement proper infection control measures for a COVID-19 positive resident. Despite clear signage and available PPE, a CNA entered the resident's room without wearing the required N95 respirator, eye protection, gown, and gloves. The Infection Preventionist confirmed the need for isolation precautions, which were not followed.
Resident Fall Due to Inadequate Supervision During Bedside Care
Penalty
Summary
A deficiency occurred when a resident who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility, was not adequately supervised during personal care. The resident, who had diagnoses including dementia, dysphagia, and glaucoma, required extensive assistance and was unable to move independently. During the provision of incontinence care, a CNA positioned the resident on their side in bed and then turned away to retrieve a wet cloth from a table located diagonally behind her, leaving the resident unattended and out of her immediate reach. While the CNA's back was turned, the resident rolled off the bed and fell to the floor, sustaining a laceration to the back of the head. The bed was noted to be in its highest position at the time of the incident. The resident was found on their back, actively bleeding from the head wound. Immediate assistance was called, and the resident was transferred to the hospital emergency department for evaluation and treatment. Medical evaluation revealed that the resident required staples to close the head wound and was diagnosed with a left lateral epidural hematoma. Interviews with staff and family confirmed that the resident was completely dependent on staff for mobility and could not reposition themselves. The incident was attributed to the CNA turning away from the resident during care, resulting in a lack of adequate supervision and failure to ensure the resident's safety during a vulnerable moment.
Failure to Obtain Timely and Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain written informed consent for the administration of a psychotropic medication to one resident prior to starting the medication. The facility's policy required that psychotropic medications be administered only after obtaining informed consent from the resident or their responsible party. The resident, who was admitted with diagnoses including bipolar disorder, anemia, osteoarthritis, diabetes mellitus, hypertension, and atrial fibrillation, was assessed as having moderate cognitive impairment but was still able to make their own decisions, as their Health Care Proxy was not activated. Despite this, the resident was administered quetiapine fumerate, an antipsychotic medication, starting in early February, without any documentation of written informed consent in the medical record. Written consent was not obtained until over a month after the medication had been initiated. Furthermore, the consent form that was eventually signed did not match the resident's current medication order, as the dosage range on the consent form was lower than the actual prescribed dose. The DON confirmed that no documentation of informed consent prior to administration could be found and acknowledged that consent should have been obtained before starting the medication.
Failure to Timely Repair Bedrail Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of left above-the-knee amputation, repeated falls, and other medical conditions required bilateral bedrails for safe transfers, turning, and positioning, as documented in the physician's orders and care plan. The resident's left bedrail became detached from the bed, and although staff were aware of the issue, the bedrail was not repaired or replaced in a timely manner. The maintenance work order for the repair was not submitted until after the resident experienced a fall. On the night of the incident, the resident attempted to sit up on the edge of the bed and reached for the missing left bedrail, lost balance, and fell forward onto the floor, resulting in a right femur fracture and head injury. Staff interviews confirmed that the resident frequently self-transferred without assistance and that the left bedrail had been broken prior to the fall. The CNA and nurse on duty were aware of the broken bedrail but did not ensure that the maintenance request was promptly entered or that the resident's environment was made safe in the interim. The facility's fall reduction policy required identification of residents at risk for falls and implementation of appropriate interventions, including assistive devices. Despite this, the necessary assistive equipment was not provided as required, and the lack of timely repair or replacement of the bedrail directly contributed to the resident's fall and subsequent injury.
Failure to Assess and Document Bedrail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and made independent medical decisions, was properly assessed for the use of bedrails and that alternatives were trialed prior to their installation. The facility's policy required that the appropriateness of bedrails be evaluated in relation to the resident's condition, with documentation of alternatives explored, rationale for use, and the resident's cognitive ability. However, there was no documentation in the resident's medical record to support that an assessment for bedrail use was conducted, that alternatives were attempted, or that the continued use of bedrails was reassessed annually as required by policy. The resident, who had a history of left leg above the knee amputation, insomnia, generalized anxiety disorder, and repeated falls, was observed using bilateral quarter length bedrails. Staff interviews confirmed that the resident used bedrails for mobility and transfers, but the resident did not recall any discussion about the risks associated with bedrail use. A physical therapy screen noted the appropriateness of the bed setup but did not document any evaluation of alternatives or their outcomes. The Director of Nurses confirmed that no documentation existed to show compliance with assessment and policy requirements regarding bedrail use.
Significant Medication Error Due to Incorrect Reconciliation of Antipsychotic Order
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff transcribed the resident's hospital discharge orders for quetiapine incorrectly, resulting in the resident receiving 900 mg of quetiapine twice daily instead of the intended 900 mg once daily at bedtime. The error persisted for 25 days, during which the resident was administered a total daily dose that exceeded the usual recommended range. Nursing staff relied on the hospital discharge summary and medication list but failed to clarify the frequency of administration, despite noting that the dosage seemed excessive. The nurse did not consult further with the provider to confirm the correct order. The error was discovered when the resident became lethargic and exhibited unstable blood pressure and heart rate. Upon review, it was found that the quetiapine order had been duplicated and administered twice daily in error. The facility's policy required verification of medication orders and clarification with the provider if a dosage appeared excessive or unrelated to the resident's condition, but this process was not followed. The Director of Nursing stated that staff should have reviewed the psychiatric and provider notes to identify the discrepancy in the medication order.
Incomplete ADL Documentation for Dependent Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were dependent on staff for all activities of daily living (ADLs). For one resident with diagnoses including cerebral infarction, diabetes mellitus, and osteomyelitis, review of ADL flow sheets over multiple weeks revealed numerous shifts where all ADL care areas were left blank, indicating incomplete documentation. Specifically, there were missing entries across all three shifts on several days, despite the resident's total dependence on staff for care. Similarly, another resident with multiple diagnoses such as anemia, osteoarthritis, diabetes mellitus, bipolar disorder, hypertension, and atrial fibrillation also had incomplete ADL documentation. Over a period of nearly a month, there were multiple days where entire shifts lacked any documentation of ADL care. The facility's policy requires that each resident have an active medical record with accurately documented information, and the unit manager confirmed that CNAs are responsible for completing this documentation by the end of their shift.
Incomplete Medication Documentation and Inaccurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as evidenced by incomplete nursing documentation in the Medication Administration Record (MAR) and inaccuracies in the Controlled Substance Register. The MAR for the resident showed blank spaces for scheduled medications, indicating that the nurse did not document the administration of medications such as Clonazepam and Oxycodone on multiple occasions across January, February, and March 2025. Interviews with nursing staff confirmed that blank spaces on the MAR suggest that the medications were not documented as administered, which is against the facility's policy. Additionally, the Controlled Substance Register for the resident contained several inaccuracies and incomplete entries. The register was missing prescription numbers, prescription dates, and accurate dosage directions for medications like Ativan, Clonazepam, and Oxycodone. The register also included incorrect dosage directions for Clonazepam and failed to document scheduled and PRN doses for Oxycodone. Interviews with nursing staff and management confirmed these discrepancies, highlighting a failure to maintain accurate records as required by the facility's policies. The resident involved had a history of brain disorders, malformations of cerebral vessels, and anxiety disorder, requiring medications such as Ativan, Clonazepam, and Oxycodone. The deficiencies in documentation and record-keeping could potentially impact the resident's care, as accurate records are essential for ensuring proper medication administration and monitoring. The facility's policies clearly outline the requirements for medication administration and documentation, which were not adhered to in this case.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for three residents, leading to deficiencies in the management of their medical care preferences. For two residents, the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) forms were not valid as they lacked the necessary signatures from the residents' Health Care Proxies (HCP) and physicians. Resident #3, who was severely cognitively impaired, had a MOLST form that was unsigned by both the HCP and the physician, despite the HCP being invoked. Similarly, Resident #62, who was cognitively impaired, had a MOLST form that was also unsigned by the HCP and physician, even though the HCP had been invoked. The social worker acknowledged that these forms were invalid and should have been updated. Additionally, the facility did not offer Resident #39 the opportunity to formulate a new Advance Directive after the resident's HCP was deactivated by the physician, as the resident was deemed capable of making their own medical decisions. Despite the resident being cognitively intact, there was no evidence in the clinical record that the resident was provided with the opportunity to establish a new MOLST. The social worker confirmed that a new MOLST should have been established once the resident was determined to have the capacity for informed medical decision-making.
Failure to Notify Physician of Significant Health Changes
Penalty
Summary
The facility failed to notify the Physician or Non-Physician Practitioner of significant changes in the condition of two residents, leading to deficiencies in care. For one resident with a diagnosis of Diabetes Mellitus Type 2, the facility staff did not inform the physician when the resident's blood sugar levels exceeded 400 mg/dL on multiple occasions. Despite the facility's policy requiring immediate notification of the physician for blood sugar levels above 400 mg/dL, there was no documentation of such notifications in the resident's progress notes. The Unit Manager confirmed that the physician should have been notified and that the lack of documentation was an oversight. Another resident, who was severely cognitively impaired and receiving nutrition via tube feeding, experienced a significant unplanned weight loss of 10.73% in one month. The facility's policy mandates notifying the physician and dietician of significant weight changes, but there was no evidence that the physician was informed of this resident's weight loss. Additionally, a re-weight was requested to confirm the accuracy of the recorded weight, but it was not obtained. The Unit Manager and a nurse were unaware of the re-weight request, indicating a communication breakdown within the facility. These deficiencies highlight the facility's failure to adhere to its own policies regarding the notification of significant changes in residents' conditions. The lack of communication and documentation regarding these critical health changes could potentially impact the residents' health outcomes, as timely medical intervention is crucial in managing such conditions.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion and transmission of the Minimum Data Set (MDS) Assessments for four residents, as required by the CMS Resident Assessment Instrument (RAI) guidelines. Specifically, the facility did not adhere to the required timeframes for setting the Assessment Reference Date (ARD), completing the MDS assessments, and transmitting the data to the state. For one resident, the quarterly MDS assessment was transmitted 28 days after the completion date, while another resident's admission MDS assessment was completed 17 days after the ARD. Additionally, two residents had their MDS assessments completed but not transmitted within the required timeframe. During an interview, MDS Nurse #1 acknowledged the delays in completing and transmitting the MDS assessments, citing that the facility's Corporate MDS staff is responsible for the transmission process, and the nurses do not have access to transmit the assessments themselves. The nurse confirmed that the completion date for the MDS assessment should be 14 days from the ARD, but this was not met for several residents. The deficiencies were identified through a review of clinical records and interviews with the facility's MDS nurses.
Failure to Notify State Mental Health Authority After 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 a resident. The resident, admitted in May 2024, had diagnoses including Bipolar Disorder, Major Depression, and Suicidal Ideation. Initially, the resident's PASRR Level I form indicated no need for a Level II evaluation as there were no treatments due to mental illness, no history of emergency mental health interventions, and no functional life impairments due to mental illness. However, subsequent events indicated a significant change in the resident's mental condition. On May 13, 2024, the resident reported intermittent suicidal ideation and was evaluated by a Nurse Practitioner, who determined the resident was not actively suicidal at that time. The following day, the resident was transferred to the hospital for suicidal ideation and returned after a crisis evaluation. On June 17, 2024, the resident expressed a desire to die rather than eat and had not eaten in two days, leading to another hospital transfer. Despite these significant changes, the facility did not request a PASRR Level II evaluation. During an interview, the Social Worker acknowledged that the resident's suicidal ideation should have triggered a Level II request, but it was not submitted.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide necessary care and services to address a hearing problem for a resident, leading to a deficiency. The resident, who was admitted with a diagnosis of hearing loss, had a physician's order for ancillary and specialty care as needed. Despite a request for audiology services being made by the resident's representative, the facility did not provide these services. The resident's Minimum Data Set (MDS) assessments indicated a decline in hearing ability, yet no hearing aids were provided, and the resident was only sometimes able to understand others. During an interview, the resident expressed significant difficulty in hearing and understanding, stating they were very deaf and unable to read lips. The clinical record review confirmed that the resident had not been referred to an audiologist, despite the family's consent for such services. The Director of Nursing acknowledged that the resident should have been referred to an audiologist, highlighting a lapse in the facility's coordination and provision of necessary care for the resident's hearing deficit.
Failure to Administer Correct Enteral Nutrition Volume
Penalty
Summary
The facility failed to administer the correct volume of enteral nutrition as per the Physician's orders for a resident who relied solely on tube feeding for nutrition. The resident, who was admitted with diagnoses including Subarachnoid Hemorrhage and Respiratory Failure, was severely cognitively impaired and received nutrition via a feeding tube. The facility's policy required that enteral feeding orders be followed to ensure consistent volume infusion, but this was not adhered to in the case of the resident. During an observation, a nurse administered only 240 ml of Osmolite 1.5 CAL tube feeds instead of the prescribed 356 ml, resulting in a deficit of 119 ml. The nurse acknowledged the error and the importance of providing the correct volume, as the resident's sole source of nutrition was through the enteral feeds. This failure to follow the Physician's orders placed the resident at risk for altered nutritional status.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not maintaining the oxygen concentrator filter in a clean, safe, and functional manner as per physician orders. The resident, who was admitted with diagnoses including asthma and acute respiratory failure, had a physician's order for continuous oxygen delivery at one liter per minute via nasal cannula. The order also specified that the oxygen concentrator filter should be cleaned weekly during the night shift every Friday. However, observations on multiple dates revealed a thick coating of gray dust on the filter, indicating that the cleaning had not been performed as required. The Unit Manager confirmed during an interview that the filter cleaning was documented as completed on the specified dates, but the physical condition of the filter suggested otherwise. The failure to clean the filter as ordered placed the resident at risk for impaired oxygen delivery and potential equipment malfunction. The Unit Manager acknowledged the importance of maintaining clean filters to prevent equipment issues and protect residents with respiratory conditions from allergens and germs.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had been admitted with quadriplegia and was dependent on staff for oral hygiene. Despite having a signed consent for dental services dated December 3, 2019, and a physician's order for a dental consult from December 8, 2020, the resident had not been referred for dental care. The resident, who was cognitively intact, expressed during an interview that they had never been seen by a dentist and relied on their brother for assistance with oral hygiene. The facility's policy required coordination with ancillary services, including dental care, based on individual needs. However, a review of the resident's medical records showed no indication of any dental consultation or treatment. The Director of Nursing confirmed that the resident had not been seen by a dentist, acknowledging that the resident should have received dental services as consent had been provided by the resident's representative.
Failure to Maintain Sanitary Conditions in Unit Kitchenettes
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in three unit kitchenettes, specifically on the F Wing, C Wing, and A Wing. Observations revealed that the refrigerators in these kitchenettes had sticky red and brown substances splattered on the inside of the doors and shelves. Additionally, the microwave in the F Wing kitchenette had food debris splattered inside. Interviews with staff, including a Unit Manager, a Certified Nurses Aide, and a Nurse, indicated a lack of clarity regarding responsibility for cleaning these appliances. The staff acknowledged the unsanitary conditions and expressed uncertainty about who should be notified for cleaning. Further investigation revealed that the refrigerator in the A Wing kitchenette contained three plastic containers of food that were unlabeled and undated, contrary to the facility's policy requiring food to be dated and tightly sealed. The Food Service Director confirmed that the Dietary department was responsible for maintaining and cleaning the appliances in the unit kitchenettes. However, there was no routine maintenance and cleaning schedule in place for these appliances, which contributed to the unsanitary conditions observed by the surveyor.
Failure to Document Social Service Support for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required support services after multiple hospital evaluations for suicidal ideation. The facility's policies on responding to self-harm and behavior management require thorough documentation of behaviors, interventions, and social service visits. However, the facility did not document social service supportive visits for the resident after incidents of suicidal ideation, despite the resident's history of mental health issues, including bipolar disorder and major depression. The resident, who was cognitively intact, expressed suicidal ideation on several occasions, leading to hospital evaluations. Despite the facility's policy requirements, there was no documentation of social service visits following these incidents. The social worker acknowledged the lack of documentation and admitted to not recording supportive visits, which should have been documented according to the facility's policies.
Inadequate PPE Use for COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement appropriate infection control measures for a resident who tested positive for COVID-19. According to the facility's Infection Prevention and Control Program, healthcare providers are required to wear an N95 respirator, eye protection, gown, and gloves when caring for residents with confirmed COVID-19 infections. Despite these guidelines, a Certified Nurses Aide (CNA) entered the room of the infected resident without donning the necessary personal protective equipment (PPE), including a gown, N95 respirator, eye protection, and gloves. The incident was observed by a surveyor, who noted the presence of a clear plastic bin containing PPE and an isolation sign outside the resident's room, indicating the required precautions. The CNA admitted to not paying attention to the isolation sign and failing to wear the required PPE. The Infection Preventionist confirmed that the resident was on isolation precautions due to a positive COVID-19 test and stated that all staff should have adhered to the posted instructions for PPE use when entering the room.
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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