Andover Forest Post Acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Andover, Massachusetts.
- Location
- 1801 Turnpike Street, North Andover, Massachusetts 01845
- CMS Provider Number
- 225530
- Inspections on file
- 21
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Andover Forest Post Acute Care Center during CMS and state inspections, most recent first.
Four residents did not receive care in accordance with professional standards: one resident used a cervical collar without a physician's order or care plan documentation; two residents received acetaminophen without timely documentation in the eMAR; and another resident with a PICC line did not have required external length or arm circumference measurements documented, with staff unaware of the policy requirements.
Three dependent residents did not receive required assistance with ADLs, including bathing, eating supervision, and denture care. One resident was not bathed as scheduled, another with severe cognitive impairment and dysphagia was left unsupervised during meals despite care plans and therapy recommendations, and a third with dementia did not receive help managing dentures, resulting in lost or unavailable dentures during meals. Staff interviews and documentation revealed a lack of awareness and missing care plan interventions for these needs.
Surveyors found that staff did not consistently date or discard medications with shortened expiration dates, such as insulin pens, inhalers, and eye drops, according to manufacturer guidelines. Medication and treatment carts, as well as the medication room, were left unlocked and unattended, allowing unauthorized access to drugs and biologicals. Staff and the DON confirmed these practices were not in line with facility policy.
A resident with intact cognition and no invoked Health Care Proxy had a MOLST form signed by a Health Care Agent instead of signing it personally, contrary to facility policy and legal requirements. The Social Worker confirmed the resident was alert and oriented, and there was no documentation authorizing the Health Care Agent to sign on the resident's behalf.
A resident with dementia and severe cognitive impairment had a nightstand with a large crack and jagged edge that prevented the drawer from closing and posed a risk of injury. Despite staff awareness of the broken furniture for several months, no maintenance request was made, and the nightstand remained in disrepair and within the resident's reach.
A resident with dementia and intact cognition, whose preferred language is Spanish, did not have a care plan addressing their communication needs. Staff were not fluent in Spanish and could only use basic words, and the care plan lacked instructions for effective communication, despite facility policy requiring documentation of language needs.
A resident with multiple chronic conditions was found using an air mattress without an active physician order, and weekly skin checks ordered by the physician were not documented for over five weeks. Staff confirmed that both the use of the air mattress and the completion of skin checks require proper orders and documentation, but these were not present in the medical record.
A resident with a stage 3 sacral pressure ulcer and spinal cord injury was placed on a low air loss mattress without a physician order, and the mattress was set incorrectly for the resident's weight. Nursing staff and the DON confirmed that an order was required and that mattress settings should match the resident's weight, but these steps were not followed, resulting in inadequate pressure ulcer management.
A resident with severe cognitive impairment and a chronic indwelling urinary catheter did not have physician orders specifying catheter size, bulb size, frequency of changes, or irrigation. Nursing staff performed catheter changes and irrigations without required physician authorization, and no anchoring system was in place to prevent dislodgement. Facility staff confirmed that proper orders were not obtained for the resident's catheter care.
Two residents did not receive necessary behavioral health care and services as required. One resident with a history of alcohol abuse was not offered substance use support services or a care plan until more than two weeks after admission, despite being cognitively intact and motivated for sobriety. Another resident with severe cognitive impairment and on Depakote did not have recommended labs or monitoring completed, even after multiple recommendations from behavioral health and pharmacy staff. Staff interviews confirmed these failures were due to lapses in assessment, care planning, and follow-through on recommendations.
Staff failed to maintain accurate medical records for two residents: one was documented as wearing a fracture boot despite not having it, and another had weekly skin checks marked as completed without supporting documentation in the medical record. Interviews with nursing staff and the DON confirmed the inaccuracies and missing documentation.
A resident with a central line for dialysis and a history of multidrug-resistant organism exposure did not have enhanced barrier precautions implemented as required by facility policy and physician orders. Observations showed no precaution signage or PPE near the room, and staff confirmed that only standard precautions were being used despite the resident's risk factors.
A resident with Alzheimer's disease and dysphagia, requiring supervision during meals, experienced a choking incident when served whole meatballs instead of the prescribed chopped meat. The resident's care plan and physician's orders specified a regular diet with chopped meat, but meal trays were not checked to ensure compliance. The incident highlighted the importance of adhering to dietary requirements and proper meal preparation protocols in LTC facilities.
The facility failed to assess for eligibility and offer pneumococcal vaccinations per CDC recommendations and facility policy for two residents. Both residents had no documentation indicating they were educated about the benefits and potential side effects of the immunization, nor records showing they received or refused the vaccine.
The facility failed to ensure that essential mechanical equipment was in safe, operating condition. Two elevators were not in safe operating condition since December 2023, affecting residents' ability to attend activities and receive timely food delivery. Additionally, the heat in the main dining room was not operational since December 2023, preventing residents from eating their meals there. The Maintenance Director acknowledged ongoing issues with the servicing companies for both the elevator and the heating system.
The facility failed to accurately complete an MDS assessment for a resident, incorrectly coding a resolved pressure ulcer as still present. The MDS Nurse used outdated information and did not conduct a current assessment or interview direct care staff, leading to the deficiency.
The facility failed to provide necessary supervision for a resident with severe cognitive impairment during meals and did not update the care plan for another resident after an incident of assaultive behavior and revocation of smoking privileges. Observations and staff interviews revealed inconsistencies and lack of documentation in the care plans.
The facility failed to review and revise a resident's care plan with the IDT after each MDS assessment. Despite the resident's pressure ulcer being resolved, the care plan was not updated, and interventions were not revised accordingly. Staff confirmed the resident had not used protective boots or received treatment for a long time.
A resident with Alzheimer's disease and full incontinence did not receive timely incontinence care, resulting in a heavily soiled brief. Observations over two days showed the resident was not checked or changed for extended periods, and staff interviews confirmed the lack of care.
A resident with macular degeneration and legal blindness did not receive follow-up vision services as recommended by an optometrist. Despite expressing a desire to see their community eye doctor and having a physician's order for vision evaluation, the facility staff failed to schedule the necessary appointment.
The facility failed to provide weekly cleanings of an oxygen concentrator filter for a resident with COPD and emphysema. The filter had not been checked for cleanliness in 35 days, and staff were unaware of the maintenance requirements.
The facility failed to develop a trauma-informed care plan for a resident with PTSD, despite the resident being cognitively intact and having difficulty adjusting to the facility. The social worker was unaware of the PTSD diagnosis, indicating a lack of communication and proper care planning.
The facility failed to ensure pharmaceutical services met the needs of a resident by not having the prescribed medication, spironolactone, available for administration on two consecutive days. The nurse did not notify the pharmacy or the physician about the unavailability, contrary to the facility's policy.
The facility failed to secure medications for a resident, as observed by a surveyor who found a bottle of Naproxen, saline nose spray, and eye drops on the resident's nightstand. The resident's clinical record did not indicate any assessment or physician's order for self-administration of these medications. Staff were unaware of the resident keeping medications at bedside, indicating non-compliance with the facility's medication storage policy.
A resident admitted with multiple diagnoses, including legal blindness and chronic pain syndrome, did not receive necessary dental services for denture replacement despite multiple requests and recommendations. The facility staff acknowledged the oversight but failed to follow up on the denture fabrication request.
A facility failed to follow a prescribed therapeutic diet and fluid restriction for a resident with a history of kidney transplant and end-stage renal disease. The facility did not ensure proper fluid distribution between dietary and nursing staff, leading to inconsistencies in fluid amounts provided. Nursing staff and the unit manager were unaware of the specific fluid amounts allowed, and the resident's fluid intake was not adequately tracked.
The facility failed to store food in a clean, sanitary, and safe manner. Observations revealed unlabeled and undated salads, loosely wrapped sandwiches, and improperly sealed hard-boiled eggs in the walk-in refrigerator. The Food Service Director confirmed the expectation for proper labeling, dating, and sealing of all foods.
The facility failed to maintain accurate medical records for a resident, documenting blood pressure readings from the left arm when they were actually taken from the right arm, despite explicit instructions to avoid the left arm due to a dialysis AV fistula.
A nurse failed to perform hand hygiene after handling a resident's draining leg and removing gloves, potentially contaminating medication cards and the medication cart. The nurse admitted to not washing or sanitizing his hands, despite knowing the requirement for hand hygiene.
The facility failed to post nurse staffing information daily, as required by federal regulations. The survey team was unable to locate the postings on multiple days, and both the Scheduler and the DON confirmed the information was not posted as required.
Failure to Follow Professional Standards in Physician Orders, Medication Documentation, and PICC Line Monitoring
Penalty
Summary
The facility failed to ensure that four residents received care in accordance with professional standards of practice. For one resident with a C4 spinal cord injury, there was no physician's order for the use of a cervical collar, despite hospital discharge instructions and physician notes indicating the need for continuous use of the collar. The resident's care plan and Kardex also lacked any mention or instructions regarding the cervical collar, and staff were unaware of the requirement, leading to inconsistent use and lack of documentation when the resident was noncompliant. Two other residents did not have timely documentation of acetaminophen administration. In both cases, nurses administered acetaminophen as needed for pain or fever but failed to document the administration in the electronic medication administration record (eMAR) at the time of administration. Both nurses acknowledged forgetting to document the medication, and there were no emergent situations that would have justified the delay. The facility's policy requires immediate documentation of medication administration, which was not followed in these instances. For another resident with a peripherally inserted central catheter (PICC line), the facility did not obtain or document the required external measurements of the PICC line or the resident's arm circumference upon admission or during dressing changes, as required by facility policy and physician orders. The hospital discharge paperwork also lacked these measurements, and staff did not contact the hospital to obtain them. The resident's care plans, nurse progress notes, and practitioner notes did not include any documentation of these measurements, and staff were uncertain about the policy and whether the required monitoring had been completed.
Failure to Provide Required ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three dependent residents, resulting in deficiencies in bathing, eating supervision, and denture care. One resident with an amputation and diabetes, who was cognitively intact and required substantial assistance with bathing, was not provided with any bathing or washing assistance over a weekend, as confirmed by both the resident and documentation. The care plan specified the need for extensive staff assistance with bathing and personal hygiene, but this was not carried out as required. Another resident with severe cognitive impairment, dysphagia, and a history of stroke required supervision or touching assistance while eating, as indicated by the care plan, physician orders, and speech therapy recommendations. Despite this, the resident was repeatedly observed eating alone in their room with the privacy curtain drawn, making them unobservable from the hallway. Staff did not check in during meals, and documentation showed that supervision was not provided for the vast majority of meal opportunities in the previous month. Interviews with staff revealed a lack of awareness regarding the resident's need for supervision during meals. A third resident with dementia and moderate cognitive impairment required partial assistance with oral hygiene and denture management. Observations showed the resident's dentures were left on the floor and not available during meals, and the resident reported frequent loss and lack of staff assistance with denture care. The care plan, physician orders, and Kardex did not include any interventions for denture management, despite repeated incidents of lost or broken dentures and staff acknowledging the resident's need for assistance. Interviews confirmed that staff were unclear about their responsibilities for denture care due to missing information in the care documentation.
Failure to Properly Store and Secure Medications
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal laws, as well as facility policy. Surveyors observed that medications with shortened expiration dates, such as insulin pens, inhalers, and eye drops, were not consistently dated when opened and were not discarded according to manufacturer guidelines. For example, insulin pens were found in medication carts well past their recommended use period after opening, and some medications were opened but undated. Staff interviews confirmed that these medications should have been dated and discarded per policy, but this was not done. Additionally, the medication room was found unlocked and unattended, allowing unauthorized access to medications. Treatment carts containing ointments and biologicals were also left unlocked and unattended on multiple occasions, making their contents accessible to anyone passing by. Staff and the DON acknowledged that medication rooms and treatment carts should always be locked when unattended, but this practice was not consistently followed.
Failure to Ensure Proper Execution of MOLST Form
Penalty
Summary
The facility failed to ensure that a resident's Medical Orders for Life Sustaining Treatment (MOLST) form was executed in accordance with its own policy and standards of practice. Specifically, the MOLST for a resident with diagnoses including hemiplegia, type 2 diabetes mellitus, and end stage renal disease was signed by an individual identified as a Health Care Agent, despite the fact that the resident was assessed as having intact cognition and there was no documentation that the Health Care Proxy had been invoked. The facility's policy requires that a MOLST form must be signed by the resident or a legally recognized representative only if the resident lacks capacity and the Health Care Proxy has been invoked. Record review showed that the resident scored a perfect 15 out of 15 on the Brief Interview for Mental Status exam, indicating full cognitive capacity, and there was no evidence in the medical record that the Health Care Proxy had been invoked. The MOLST form was completed and signed by someone other than the resident, with the box for Health Care Agent checked, and later signed by a Physician Assistant. During interview, the Social Worker confirmed the resident was alert, oriented, and that the Health Care Proxy was not invoked, and was unsure who had signed the MOLST. This failure resulted in the MOLST not being properly executed according to facility policy and legal requirements.
Failure to Maintain Safe and Functional Resident Furniture
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident with dementia and severe cognitive impairment by not maintaining the resident's nightstand in a functional and safe condition. The nightstand, located within the resident's reach, had a large crack with a jagged edge on the drawer, preventing it from closing and posing a risk of injury. The exterior of the nightstand was also in poor condition, with scratches and peeling paint. The resident's personal belongings, including a telephone, purse, and nebulizer mask, were stored in the damaged drawer. Despite the nightstand being broken since at least December, staff did not report the issue to maintenance as required by facility policy. Both a CNA and the unit manager were aware of the damage but did not initiate a maintenance request. The maintenance director confirmed that no report had been made in the facility's electronic maintenance system, and the director of nursing stated that staff are expected to promptly report such issues. The deficiency was identified through observations, interviews, and record review.
Failure to Develop Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to document and develop a care plan addressing the communication needs of a resident whose preferred language is Spanish. Despite the facility's policy requiring documentation of language and communication needs in the electronic medical record and the provision of language services at no charge, the resident's care plan did not include any information about their preferred language or instructions for staff on how to communicate effectively. The Minimum Data Set (MDS) indicated the resident had intact cognition and specifically requested an interpreter for communication with healthcare staff, but this was not reflected in the care plan. Interviews with the resident and staff confirmed that the resident speaks only Spanish and does not speak English. Nursing staff administering medication to the resident were not fluent in Spanish and could only communicate using a few basic words. Both the Assistant Director of Nurses and the Social Worker acknowledged that a person-centered communication care plan identifying the resident's preferred language should have been in place to guide staff interactions and ensure the resident's needs were met.
Failure to Obtain Physician Order for Air Mattress and Complete Weekly Skin Checks
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for one resident. Specifically, the resident, who had diagnoses including bipolar disorder, type 2 diabetes, and dementia, was observed using an air mattress on multiple occasions. However, there was no active physician's order or care plan documentation authorizing the use of the air mattress, despite staff acknowledging that such an order is required. The air mattress was set to a weight significantly higher than the resident's actual weight, and staff interviews confirmed that the resident had been transferred with the air mattress but lacked the necessary physician's order. Additionally, the facility did not ensure that weekly skin checks were performed and documented as ordered by the physician. The resident's medical record showed that the last completed skin check was over five weeks prior to the survey, despite an active order for weekly checks. Staff interviews revealed that the resident was not resistive to care, and both nursing staff and the DON confirmed that skin checks should be documented regardless of findings. The lack of documentation indicated that the required skin checks were not completed or recorded as ordered.
Failure to Obtain Physician Order and Properly Set Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for a resident with a stage three sacral pressure ulcer and spinal cord injury. The resident was dependent on staff for bed mobility and had a documented recommendation from a wound consultant for a low air loss mattress. Despite this, there was no physician order for the use of an air mattress, and the resident's care plan did not include the use of such a device. The resident was observed on multiple occasions using a Medline Supra APL air mattress, but the mattress was set to 240 pounds, which did not correspond to the resident's actual weight, which ranged from 152 to 166 pounds during the relevant period. Interviews with nursing staff and the DON confirmed that a physician order is required for air mattress use and that mattress settings should be based on the resident's weight according to manufacturer guidelines. Staff acknowledged that the air mattress should have been set according to the resident's weight and that the absence of a physician order was an oversight. The facility did not have a written policy for air mattresses but expected staff to follow manufacturer guidelines. These failures resulted in the resident not receiving appropriate pressure ulcer management as recommended.
Lack of Physician Orders for Indwelling Urinary Catheter Care
Penalty
Summary
The facility failed to follow professional standards of practice for the care of an indwelling urinary catheter for one resident. The resident, who had severe cognitive impairment and a chronic indwelling urinary catheter due to benign prostatic hyperplasia, did not have appropriate physician orders for the use and care of the catheter. Specifically, there were no orders specifying the catheter size, bulb size, frequency of catheter or catheter bag changes, or instructions for irrigation. Despite this, nursing staff changed the catheter and irrigated it on multiple occasions without obtaining the required physician orders. Observations confirmed the resident had an indwelling urinary catheter in place, and there was no anchoring system to prevent accidental dislodgement. Interviews with facility staff, including the Unit Manager and DON, confirmed that physician orders are required for all aspects of catheter care, and acknowledged that such orders were not obtained for this resident. Documentation also showed that catheter care activities, such as changes and irrigation, were performed without the necessary physician authorization.
Failure to Provide Timely Behavioral Health Services and Implement Recommendations
Penalty
Summary
The facility failed to provide timely and appropriate behavioral health care and services to two residents, as required by their own policies and comprehensive care plans. One resident was admitted with a history of alcohol abuse and withdrawal, including a recent episode of seizures related to withdrawal. Despite being cognitively intact and expressing motivation for sobriety, the resident was not offered behavioral health or substance use support services upon admission. The care plan addressing substance use was not implemented until 17 days after admission, and only after the resident was found with alcohol in the facility. Interviews with staff confirmed that the resident should have been assessed and offered support services within the first week, but this did not occur. Another resident, admitted with diagnoses including cerebral infarction, dysphagia, and muscle weakness, exhibited severe cognitive impairment and behavioral symptoms. The resident was prescribed Depakote for depression, and a behavioral health nurse practitioner recommended obtaining a Depakote level, lipid profile, and EKG. The facility's pharmacist also noted that the Depakote drug level was overdue and recommended ordering the necessary labs. However, a review of the medical record showed that these recommended labs were never obtained, and the facility was unable to provide evidence of completed labs when requested by the surveyor. Interviews with facility staff revealed that recommendations from behavioral health services were uploaded to the electronic medical record and sent to the unit manager, but the unit where the resident resided did not have a unit manager at the time, resulting in a lack of follow-through. The DON acknowledged that the recommended labs should have been obtained shortly after they were recommended, but this did not occur, indicating a breakdown in the process for implementing behavioral health recommendations.
Failure to Maintain Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with a history of dementia and a recent right metatarsal fracture, staff documented in the Treatment Administration Record that the resident was wearing a fracture boot as ordered by the physician, despite the resident discarding the boot upon readmission and not wearing it during the survey period. Multiple staff interviews confirmed that the resident was not wearing the boot, and the Director of Nursing acknowledged that documentation should not have indicated the boot was being worn when it was not. For another resident with bipolar disorder, type 2 diabetes, and dementia, staff documented weekly skin checks as completed in the Treatment Administration Record, but the medical record did not contain documentation of these checks for a five-week period. Review of the resident's record showed the last documented skin check was several weeks prior, and staff could not account for the missing documentation. The Director of Nursing confirmed that skin checks must be documented in the medical record, regardless of findings.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) in accordance with its own infection control policy for a resident with an indwelling medical device. The resident, who was readmitted with a history of resistance to multiple antimicrobial drugs and dependence on renal dialysis, had a central line (internal jugular catheter) for dialysis access. The care plan included interventions for EBP during personal care, and there was a physician's order for EBP. However, multiple observations revealed that there was no enhanced precaution sign on the resident's door, no personal protective equipment (PPE) available near the room, and no indication that staff were following EBP protocols during high-contact care activities. Interviews with nursing staff and the infection control preventionist confirmed that the resident had an indwelling medical device and that EBP should have been implemented, including signage and PPE availability. Despite this, staff reported that only standard precautions were being used, and the required EBP measures were not in place as per facility policy and physician orders. These findings demonstrate a failure to follow established infection prevention and control procedures for residents with indwelling medical devices.
Dietary Oversight Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that Resident #68 received the proper diet form as ordered by the physician, leading to a choking incident during lunch on 1/22/24. Resident #68, admitted in December 2017 with Alzheimer's disease and diagnosed with dysphagia in July 2019, required supervision for meals as per the MDS assessment. Despite having a care plan specifying the need for assistance and supervision during meals, there was no documentation indicating the level of assistance required for eating. The physician's order from 11/19/19 through 1/22/24 prescribed a regular diet with regular texture and chopped meat for Resident #68. During the incident, Resident #68 was served whole meatballs instead of chopped meat as ordered, resulting in choking and the need for the Heimlich maneuver. Interviews with family members, nurses, and the Speech and Language Pathologists revealed that the meal trays were not checked to ensure the correct diet was delivered. The facility's failure to provide Resident #68's meal in the proper form as ordered by the physician was a critical oversight, especially considering the resident's history of dysphagia and the specific dietary requirements outlined in the care plan and physician's orders. Despite the clear instructions in the therapeutic diet manual and the physician's order for chopped meat, the facility served whole meatballs to Resident #68. The lack of proper oversight by nursing staff, including not checking meal trays and ensuring the correct diet was delivered, contributed to the deficiency. The failure to follow established protocols for residents with specific dietary needs, such as Resident #68, resulted in a serious adverse event that required immediate intervention and highlighted the importance of proper meal preparation and service in long-term care facilities.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to assess for eligibility and offer pneumococcal vaccinations per CDC recommendations and facility policy for two residents. Resident #49, admitted in March 2024 with a diagnosis of diabetes, had no documentation in the medical record indicating that the resident or their representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization. Additionally, there was no record that the resident either received the pneumococcal immunization or did not receive it due to medical contraindication or refusal. The Minimum Data Set (MDS) assessment for Resident #49 indicated that the pneumococcal vaccination was not up to date and had not been offered. Similarly, Resident #87, admitted in March 2021 with diagnoses including dementia and obesity, also had no documentation in the medical record showing that the resident or their representative was educated about the pneumococcal immunization. The MDS assessment for Resident #87 indicated that the pneumococcal vaccination was not up to date and had not been offered. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility did not have documentation to support that either resident was educated, offered, or received the pneumococcal immunizations as required by the facility's policy.
Failure to Maintain Essential Mechanical Equipment
Penalty
Summary
The facility failed to ensure that essential mechanical equipment was in safe, operating condition. Specifically, two of the facility's elevators were not in safe operating condition since December 2023. Upon entry to the facility, surveyors observed one of the two elevators was out of order. Multiple residents reported that having only one working elevator for months affected timely food delivery and their ability to attend activities. The Ombudsman confirmed that the elevator had been out of order for months, causing significant issues for residents and visitors. The Maintenance Director acknowledged the ongoing issues with the servicing company, including concerns related to the cost of fixing the elevator and potential penalties for breaching the contract. Emails between the facility and the elevator service company indicated that the non-working elevator had been down since December 2023, with ongoing concerns about the cost and payment for repairs and services, and the servicing company’s inability to staff or send out employees for repairs. The Maintenance Director could not explain why an alternative company had not been utilized to expedite the repairs of the elevator. Additionally, the facility failed to ensure that the heat in the main dining room on the ground floor was operational since December 2023. Surveyors observed that no residents were eating their meals in the main dining room during breakfast and lunch meals. Resident Council meeting minutes and interviews with residents and staff confirmed that the main dining room had not been used for meals due to the lack of heat. The Maintenance Director mentioned ongoing communication with the servicing company regarding repairing the heat and the need to either replace parts or completely replace the unit for the main dining area. Emails indicated that the heat was not functioning since January 2024, and quotes to replace the system had been approved by the facility in February and March 2024. As of the date of the survey, the heat was still not operational in the main dining room.
Inaccurate MDS Assessment for Resolved Pressure Ulcer
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. Specifically, the MDS Nurse incorrectly coded a resolved pressure ulcer as still present for a resident. The resident had been admitted with diagnoses including diabetes, adult failure to thrive, and dysphagia. The MDS assessment dated 2/28/24 indicated the resident had a stage two pressure ulcer, but the ulcer had actually been resolved as of 12/6/23, according to the hospice wound record report and observations by the surveyor and staff interviews. The MDS Nurse admitted to coding the pressure ulcer based on outdated information from December 2023 and did not conduct a current assessment or interview direct care staff. The Director of Nursing confirmed that the MDS Nurse should have followed the Resident Assessment Instrument (RAI) Manual for completing MDS assessments. This failure to accurately assess and document the resident's condition led to the identified deficiency.
Failure to Implement and Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure the plan of care was developed and implemented for two residents. For Resident #10, who has severe cognitive impairment and requires supervision and assistance with eating, the facility did not provide continual supervision during meals. Observations over several days showed Resident #10 eating alone in his/her room without staff present, despite the care plan and Kardex indicating the need for continuous supervision. Interviews with staff revealed inconsistencies in understanding and implementing the required level of assistance for Resident #10 during meals. For Resident #102, who has a history of restlessness, agitation, and adjustment disorder with depressed mood, the facility failed to update the care plan after an incident of assaultive behavior toward staff. Resident #102's smoking privileges were revoked following the incident, but the care plan did not reflect this change or the new arrangement for family to supervise smoking. Interviews with staff confirmed the incident and the change in smoking supervision, but the medical record and care plan lacked documentation of these updates. These deficiencies highlight the facility's failure to adhere to its policies on providing necessary care and services for residents who cannot carry out activities of daily living independently and to update care plans to reflect significant changes in residents' conditions and behaviors.
Failure to Review and Revise Care Plan with IDT
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised with the interdisciplinary team (IDT) as required for one resident. Specifically, the facility did not review and update Resident #59's skin care plan after each Minimum Data Set (MDS) assessment. Resident #59, who was admitted in May 2019 with diagnoses including diabetes, adult failure to thrive, and dysphagia, had a stage two pressure ulcer as indicated in the MDS assessment dated 2/28/24. Despite the pressure ulcer being resolved by 12/6/23, the care plan was not updated to reflect the current status, and interventions such as the use of protective boots and Xerofoam dressings were not revised accordingly. Observations and interviews revealed that Resident #59 did not have any pressure ulcers and was not using protective boots or receiving treatment on the left heel at the time of the survey. Certified Nurse Assistants and nurses confirmed that the resident had not worn booties for a long time and that the pressure ulcer had healed months ago. The Unit Manager and the Director of Nursing acknowledged that the care plan should have been reviewed and revised during the quarterly care plan review but was not. This oversight led to the deficiency noted in the report.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for Resident #87, who has Alzheimer's disease and is fully incontinent of bladder and bowel. The resident, who is dependent on staff for all activities of daily living, was observed multiple times over two days without receiving necessary incontinence care. On the first day, the resident was observed from 8:22 A.M. to 11:27 A.M. without any staff checking for incontinence. On the second day, the resident was observed from 7:42 A.M. to 1:30 P.M. without being checked or changed, resulting in a saturated incontinence brief with a strong odor of urine, indicating multiple urinary voiding episodes. Interviews with staff confirmed that the resident had not received incontinence care for over five hours on the second day. CNA #2, who was not assigned to the resident but was helping the assigned CNA, found the resident's incontinence brief to be heavily soiled. CNA #6, who was assigned to the resident, admitted that she had not provided incontinence care since getting the resident out of bed at 7:00 A.M. Nurse #2 and the Director of Nursing both acknowledged that the resident should have been provided incontinence care every two to three hours to prevent skin breakdown.
Failure to Follow Up on Vision Services for Resident
Penalty
Summary
The facility failed to provide necessary follow-up for vision services for a resident diagnosed with macular degeneration and legal blindness. Despite a recommendation from an optometry consultation on 9/27/23 for an outside optometrist evaluation, the facility did not schedule an appointment with the resident's preferred community eye doctor. The resident, who was cognitively intact with a BIMS score of 14 out of 15, expressed dissatisfaction with the current glasses and a desire to see their own eye doctor. The physician's order from 10/31/22 and the plan of care from 11/25/22 both indicated the need for vision evaluation, but these were not adequately followed up on by the facility staff. Interviews with the resident, a Certified Nurse Assistant, the Unit Manager, and the Director of Nursing revealed that the resident's request to see their community eye doctor was known but not acted upon. The Unit Manager acknowledged the oversight in not booking the appointment, and the Director of Nursing confirmed that nursing staff should have scheduled the visit. This lack of follow-up resulted in the resident not receiving the desired and potentially necessary vision care from their preferred provider.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide weekly cleanings of an oxygen concentrator filter for a resident with chronic obstructive pulmonary disease and emphysema. The resident's physician orders required oxygen administration at 1-2 liters per minute via nasal cannula to maintain oxygen saturation greater than 90%. However, there was no reference to changing or cleaning the oxygen concentrator filter in the resident's physician orders, treatment administration record, or progress notes. The facility's nursing form indicated that oxygen concentrator filters should be checked and cleaned every Sunday night, but the filter for this resident had not been checked for cleanliness in the past 35 days. During an observation, the surveyor noted that the oxygen concentrator filter was completely covered in a layer of white dust approximately three millimeters deep. Interviews with the nursing staff revealed that they were unaware of the physician orders or facility policy regarding the maintenance of the oxygen concentrator filter. The Director of Nursing was also unable to locate any documentation indicating that weekly cleanings had occurred. This lack of awareness and documentation led to the deficiency in providing appropriate respiratory care for the resident.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for Trauma-Informed Care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, admitted in November 2023, had a BIMS score of 15, indicating cognitive intactness. Despite this, the clinical care plans reviewed on April 10, 2024, did not include a trauma-informed care plan. A family member reported the resident's difficulty in adjusting to the facility, and the social worker was unaware of the PTSD diagnosis, indicating a lack of communication and proper care planning for the resident's specific needs.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of Resident #108 by not having the prescribed medication, spironolactone, available for administration. Resident #108, who was admitted with diagnoses including hyperaldosteronism and heart failure, had a physician's order for spironolactone to be administered daily. However, during a medication pass, Nurse #2 reported that the medication was not available on two consecutive days, 4/10/24 and 4/11/24. The medication administration record confirmed that the medication was not given on these dates, and Nurse #2 admitted to not notifying the pharmacy or the physician about the unavailability of the medication. The facility's pharmacy policy outlines steps to be taken when a medication is not available, including checking neighboring medication carts, the medication room, and the cubex tower, as well as contacting the pharmacy and the prescriber. Despite these guidelines, the necessary actions were not taken to ensure the availability of spironolactone for Resident #108. The Director of Nursing confirmed that nursing staff should call the physician and the pharmacy when routine medications are unavailable, which was not done in this case.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure medications were secured for one resident out of a total of 29 sampled residents. The facility's policy, dated November 2021, mandates that medications should be stored in locked compartments when not in use. However, during an interview and observation on April 10, 2024, the surveyor found a bottle of Naproxen, saline nose spray, and eye drops on Resident #93's nightstand. Resident #93, who was admitted in June 2021 with chronic kidney disease and is cognitively intact, mentioned that his/her son brought the Naproxen, and he/she had not taken it recently due to side effects. The clinical record did not indicate any assessment or physician's order for Resident #93 to keep medications in his/her room. On April 11, 2024, the surveyor again observed the same medications on Resident #93's nightstand while the resident was not in the room. Nurse #5 and Unit Manager #2 both stated they were unaware of any residents on the unit who kept their own medications at bedside or self-administered their medications. Unit Manager #2 subsequently removed the medications from the nightstand. This indicates a failure to adhere to the facility's medication storage policy, compromising the safety and security of medications within the facility.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted in October 2022 with diagnoses including macular degeneration, legal blindness, and chronic pain syndrome. The resident, who was cognitively intact with a BIMS score of 14 out of 15, required substantial assistance with oral hygiene, including the management of dentures. Despite a physician's order from October 2022 to obtain dental services as needed, and a specific request from the resident in February 2023 to be seen by dental services, the facility did not follow up on the dental recommendations made on September 18, 2023, for the fabrication of new dentures after the resident lost their original set. The consent form for denture fabrication was left blank and not completed. Interviews with various staff members, including a CNA, a nurse, a unit manager, and the DON, revealed that the resident's need for new dentures was known but not acted upon. The unit manager and the DON both acknowledged that the nursing staff should have followed up on the denture fabrication request made in September 2023 but failed to do so. This inaction resulted in the resident not receiving the necessary dental services to replace their lost dentures, impacting their ability to chew and overall quality of life.
Failure to Follow Prescribed Therapeutic Diet and Fluid Restriction
Penalty
Summary
The facility failed to follow a therapeutic diet as prescribed by the attending physician for a resident who required a fluid restriction. The resident, who had a history of kidney transplant, end-stage renal disease with dependence on renal dialysis, heart failure, and obstructive sleep apnea, was admitted with a physician's order for a renal diet and a 2-liter fluid restriction. However, the facility did not ensure proper fluid distribution between dietary and nursing staff. The diet slips indicated inconsistencies in the fluid amounts provided, with some meals exceeding the allowed fluid limit and others not meeting the total daily fluid allotment. Additionally, the nursing staff and unit manager were unaware of the specific fluid amounts allowed by dietary and nursing, and they were not tracking the resident's fluid intake as required by the physician's order and facility policy. Interviews with the resident, nursing staff, unit manager, and the Regional Food Service Director revealed a lack of communication and coordination regarding the fluid restriction. The resident had additional fluids at the bedside that were not accounted for in the fluid restriction plan. The Director of Nursing confirmed that the fluid restriction should be broken down for both nursing and dietary staff, but this was not being done. The facility's failure to adhere to the prescribed therapeutic diet and fluid restriction resulted in a deficiency in the care provided to the resident.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure food was stored in a clean, sanitary, and safe manner to prevent the potential spread of foodborne illness to residents. During an observation, the walk-in refrigerator contained six bowls of salad with wilted yellow leaves that were covered but not labeled or dated. Additionally, twelve more bowls of salad were covered but also not labeled or dated. Approximately ten prepared sandwiches were found loosely wrapped in unsealed sandwich bags. A bucket of hard-boiled eggs was observed with the cover resting loosely on top, not tightly sealed. The Food Service Director confirmed that he would expect all foods to be labeled, dated, and properly sealed.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure nursing maintained an accurate medical record for one resident out of a sample of 29 residents. Specifically, for Resident #42, nursing documented that they obtained blood pressure from the left arm when they did not. Resident #42 was admitted with diagnoses including kidney transplant, end-stage renal disease with dependence on renal dialysis, heart failure, and obstructive sleep apnea. The care plan and physician's orders explicitly stated that no blood pressure should be taken from the left arm due to a dialysis AV fistula. However, records indicated that blood pressure readings were documented as being taken from the left arm on multiple dates in March and April 2024. Interviews with Resident #42 and nursing staff revealed that blood pressure was actually taken from the right arm, contrary to what was documented. Resident #42 confirmed that staff only checked blood pressure on the right arm. Nurses #7 and #8, as well as the Unit Manager and the Director of Nursing, acknowledged that the correct arm should have been documented. Nurse #8 admitted to not accurately documenting the correct arm used for blood pressure readings. This discrepancy in documentation was confirmed by multiple staff members, including the Director of Nursing, who stated that nursing should document the correct arm used for obtaining blood pressure readings.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented to prevent the spread of infection on one of the three resident care units. Specifically, a nurse was observed handling a resident's draining leg while wearing gloves, then removing the gloves and touching medication cards without performing hand hygiene. This action potentially contaminated the desk, individual resident's medication cards, and the medication cart. During an interview, the nurse admitted to not washing or sanitizing his hands after removing the gloves, despite knowing that hand hygiene is required after being in contact with a resident and after glove removal. This failure to follow proper hand hygiene protocols was observed and documented by the surveyor, highlighting a significant lapse in infection control practices within the facility.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post nurse staffing information daily, at the start of each shift, as required by federal regulations. Specifically, the survey team was unable to locate the required nurse staffing information postings on 4/10/24, 4/11/24, and 4/12/24. During an interview on 4/12/24 at 9:46 A.M., the Scheduler admitted to not posting the staffing information as required. Additionally, during an interview on 4/12/24 at 10:38 A.M., the Director of Nursing (DON) confirmed that the nurse staffing information should be posted according to federal requirements.
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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