Aspen Hill Rehabiliation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 190 North Avenue, Haverhill, Massachusetts 01830
- CMS Provider Number
- 225404
- Inspections on file
- 28
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Aspen Hill Rehabiliation & Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple health conditions required staff assistance for ambulation, as per their care plan. However, a CNA allowed the resident to ambulate independently, resulting in a fall and injury. The CNA had not reviewed the resident's Kardex and mistakenly believed the resident was independent. Other staff were either unaware of the resident's needs or not present during the incident.
A resident at risk for falls, requiring assistance with ambulation, was left unsupervised and fell, resulting in a laceration requiring hospital treatment. The CNA on duty was unable to assist due to other responsibilities and attempts to alert a nurse were unsuccessful. The incident highlights a failure in staff communication and supervision.
A resident reported rough handling by a CNA, but the facility did not take immediate action, leading to another incident where a different resident suffered a fracture due to the same CNA's actions. The facility's failure to follow its abuse prevention and investigation policies resulted in continued risk to residents.
A facility failed to investigate an allegation of rough handling by a CNA, reported by a resident with intact cognition. The incident was not documented or thoroughly investigated, allowing the CNA to continue working. This led to another incident where the same CNA was reported for rough handling, resulting in a resident's arm fracture. The facility's inadequate response to the initial report violated its policy on abuse investigation.
The facility failed to meet professional standards for four residents, including not applying physician-ordered compression stockings, incorrect g-tube flush settings due to unclarified orders, lack of speech therapy evaluation for diet consistency, and missing scheduled weigh-ins for a resident at risk of malnutrition.
The facility failed to maintain sufficient staffing levels on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. The report showed excessively low weekend staffing, triggering a concern for follow-up. The facility's staffing plan required 15 licensed nurses and 30 nurse aides, with 3.20 HPPD for direct care, but this was only met in one out of 12 weeks. The Administrator noted past recruitment difficulties, though staffing has improved with on-call nursing management.
The facility failed to label and date medications according to guidelines, with several medications found open and undated on two medication carts. Additionally, a medication cart on the Dementia Unit was left unlocked and unattended. Staff interviews confirmed the need for proper labeling and secure storage of medications.
The facility failed to schedule recommended specialist appointments for cataract surgery for three residents, despite recommendations from a consulting eye doctor. The residents expressed frustration over worsening vision, and the outpatient eye doctor's office confirmed no referrals were received. The Director of Nurses expected follow-ups within a week, but this was not done, indicating a lapse in managing specialist referrals.
The facility failed to ensure accurate documentation and medication administration for several residents. One resident's oxygen settings and equipment changes were inaccurately documented, while another's antipsychotic medication lacked an associated diagnosis. A diabetic resident received insulin later than documented, and another resident's blood pressure was recorded from the wrong arm. These discrepancies were confirmed through observations and staff interviews.
A facility failed to investigate an abuse allegation from a resident, leading to further abuse by the same CNA. The resident reported rough handling and incorrect brief sizing, but the incident was treated as a grievance. The facility's policy requires thorough investigation and reporting, which was not followed. Another resident later reported physical abuse by the same CNA, resulting in pain and a fracture. The CNA was eventually terminated, but the initial failure to investigate allowed further harm.
A resident reported rough handling by a CNA during a transfer, including being forced to use an incorrect size brief. The facility failed to report the incident as potential abuse, categorizing it instead as a customer service issue. The incident was not documented in the medical record or reported to authorities, contrary to facility policy.
A facility failed to implement a comprehensive care plan for a resident with cognitive impairment and a history of falls, neglecting to use fall mats as specified. Despite multiple falls and injuries, staff were unaware or unable to locate the mats, highlighting a disconnect between the care plan and its execution.
A resident with congestive heart failure did not have daily weights obtained for three consecutive days due to a broken scale, leading to a 5.2-pound weight gain. The facility staff failed to use alternative scales, and management was unaware of the issue until it was documented in nursing progress notes.
A facility failed to obtain a physician's order for the appropriate settings of an air mattress for a resident with pressure ulcers. The resident, with moderate cognitive impairment and weighing 148.7 lbs, was observed on an air mattress set at 175 lbs. Staff interviews revealed that the mattress should be set according to the resident's weight to prevent skin breakdown, but no physician's order was present to guide the settings.
A resident's PICC line dressing was not changed as required, and weekly measurements were not taken to ensure the line had not migrated. The LPN involved was not trained to change PICC line dressings, leading to a deficiency in care.
A facility failed to adhere to a physician's orders for a resident with Acute Respiratory Failure, providing oxygen at 3L instead of the prescribed 2L, not changing the oxygen tubing as scheduled, and omitting foam ear protectors. Documentation inaccurately reflected compliance, while observations and staff interviews confirmed the discrepancies.
The facility failed to develop trauma-informed care plans with resident-specific triggers and interventions for two residents with PTSD. One resident had intact cognition but was inaccurately assessed as not having past trauma, while another had severe cognitive impairment with a care plan lacking specific interventions. Interviews revealed acknowledgment of assessment inaccuracies and expectations for resident-specific care plans.
A resident with Parkinson's Disease, malnutrition, and depression was not provided with necessary dental care despite the facility's policy. The resident, who had multiple missing and carious teeth, reported not seeing a dentist since admission and expressed a desire for dental services to aid in chewing. The facility's documentation noted missing teeth but did not address carious teeth, and there was no record of a dental consult. The DON acknowledged the oversight.
A resident with moderate cognitive impairment did not receive necessary dental care after a dentist recommended tooth extractions and new dentures. The facility failed to follow up on these recommendations, resulting in the resident not receiving the required dental services. Staff were unaware of the need for extractions and dentures, and there was no documentation or communication regarding the dental visit and recommendations.
The facility failed to develop a QAPI plan after two residents alleged abuse by the same CNA. Despite the facility's policy requiring investigation and reporting of abuse, the QAPI plan was incomplete, with no audits or safety measures implemented. The CNA was terminated for insubordination, but the Administrator could not provide evidence of resident safety interviews or a complete QAPI plan.
The facility failed to implement contact precautions for two residents diagnosed with C. difficile and MRSA. Despite signs indicating the need for PPE, staff were observed entering and exiting rooms without proper protective measures or hand hygiene. Interviews revealed a lack of adherence to infection control protocols, compromising the facility's infection prevention efforts.
The facility failed to offer the COVID-19 vaccine to two employees during their new hire orientation, as required by policy. Both employees were informed about the vaccine and refused it, but the forms were not properly completed. The oversight occurred during the orientation sessions, and both employees have been working in the facility since then.
The facility inaccurately completed MDS assessments for two residents, leading to documentation deficiencies. One resident's dental status was misrepresented, showing no carious teeth despite having multiple missing and discolored teeth. Another resident's MDS failed to indicate a feeding tube, despite it being part of their care plan. These errors were acknowledged by the facility's nursing staff.
Failure to Implement Ambulation Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions related to ambulation for a resident who required staff assistance. The resident, who had diagnoses including chronic kidney disease, anemia, depression, anxiety, and insomnia, was assessed to need partial to moderate assistance with ambulation. However, on a specific day, a CNA observed the resident ambulating independently and did not provide the required supervision or assistance as outlined in the care plan. Consequently, the resident fell, sustained a laceration on the left eyebrow, and required hospital treatment. Interviews revealed that the CNA was familiar with the resident but had not reviewed the resident's Kardex, which indicated the need for assistance with ambulation. The CNA mistakenly believed the resident was independent with just supervision. During the incident, the CNA was unable to leave other residents unsupervised and called out to a nurse for assistance, but received no response. The Unit Manager and other nursing staff were either unaware of the resident's ambulation needs or were not present at the time of the fall. The Director of Nurses confirmed that the care plan required staff assistance for ambulation, which was not followed, leading to the resident's fall and injury.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident assessed as being at risk for falls, resulting in an incident where the resident sustained an injury. The resident, who had diagnoses including chronic kidney disease, anemia, depression, anxiety, and insomnia, was identified as requiring partial to moderate assistance with ambulation. Despite this, on the day of the incident, a Certified Nurse Aide (CNA) observed the resident ambulating alone but did not provide assistance or seek help from another staff member. The resident subsequently fell, sustaining a laceration that required hospital treatment. Interviews with staff revealed that the CNA was aware of the resident's need for supervision but was unable to assist due to other responsibilities. The CNA attempted to alert a nurse, who did not respond, and the resident was left unsupervised. The Unit Manager and the resident's usual nurse were not present at the time of the fall, and another nurse on duty did not hear the CNA's call for assistance. The Director of Nurses confirmed that the resident required assistance from one staff member for ambulation, highlighting a failure in staff communication and supervision that led to the resident's fall and subsequent injury.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) who was accused of rough handling by a resident. Resident #95, who was cognitively intact, reported that CNA #5 did not follow their preferences during a transfer and was rough, causing discomfort. Despite the resident's report, the facility administrator categorized the incident as a customer service issue rather than potential abuse, and no immediate action was taken to prevent the CNA from continuing to work with residents. Subsequently, Resident #1, also cognitively intact, reported an incident involving the same CNA. The resident stated that CNA #5 forcefully pulled a laptop case handle from their arm, causing significant pain, and was rough during care. An x-ray later revealed a fracture in the resident's arm. The facility's documentation showed that the CNA was not suspended until six days after the incident, indicating a delay in addressing the potential abuse. The facility's policies on abuse prevention and investigation were not adequately followed, as the CNA continued to work without restriction after the initial grievance was filed. The lack of immediate action and thorough investigation contributed to the subsequent incident involving Resident #1, highlighting deficiencies in the facility's response to allegations of abuse.
Failure to Investigate Alleged Abuse Leads to Further Incident
Penalty
Summary
The facility failed to investigate an allegation of potential abuse involving a resident who reported being roughly handled by a certified nursing aide (CNA). The resident, who had intact cognition and required assistance with daily activities, reported the incident to the Unit Manager, expressing that the CNA did not follow transfer preferences and was rough during the process. The resident also mentioned being pressured to use an incorrect size brief. Despite the resident's report, the facility did not thoroughly investigate the incident, as evidenced by the lack of documentation in the medical record and the absence of a written statement from the involved CNA or other staff present at the time. The administrator categorized the incident as a customer service issue rather than potential abuse, based on her interpretation of the resident's report. The Director of Nursing also inquired if the resident felt the actions were malicious, to which the resident responded negatively. However, the facility's policy requires all allegations of abuse to be thoroughly investigated, including interviews with all relevant parties and documentation of findings, which was not adequately followed in this case. As a result of the inadequate investigation, the accused CNA continued to work and subsequently was involved in another incident with a different resident. This resident reported being roughly handled by the same CNA, resulting in pain and a fracture in the arm. The facility eventually suspended and terminated the CNA, but the failure to initially investigate the first allegation allowed the CNA to continue working and potentially harm another resident.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to meet professional standards of practice for four residents, leading to deficiencies in care. For one resident, the facility did not implement physician-ordered compression stockings, which were intended to manage lower extremity edema. Despite documentation indicating that the stockings were applied, observations revealed that the resident was not wearing them, and they were found in a dresser drawer. Interviews with nursing staff confirmed that the stockings were not applied as ordered. Another resident experienced issues with enteral nutrition management. The facility failed to clarify conflicting physician orders for g-tube flushes, resulting in incorrect settings on the feeding tube pump. The resident's care plan and physician orders indicated specific flush volumes and schedules, but the pump was set incorrectly, and the orders were not clarified, leading to potential discrepancies in fluid administration. Additionally, a resident was placed on a mechanical soft diet without a recent evaluation by speech therapy, despite the resident's request for a regular diet and a hospital discharge summary indicating a regular diet. The facility's process for notifying the therapy department of diet recommendations was not followed, resulting in a lack of evaluation. Lastly, the facility did not obtain weekly weights for a resident as ordered, missing several scheduled weigh-ins, which were crucial for monitoring the resident's nutritional status given their medical history of weight loss and malnutrition.
Insufficient Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the payroll-based journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The PBJ Staffing Data Report indicated that the facility's weekend staffing levels were excessively low, triggering a concern that required follow-up during the survey. The facility's 'Facility Assessment Tool' outlined a staffing plan requiring 15 licensed nurses and 30 nurse aides, with a total of 3.20 hours per patient day (HPPD) for direct care staff. However, the facility only met this required HPPD in one out of the 12 weeks during the specified quarter. The Administrator acknowledged the difficulty in recruiting staff last year, although they have since managed to staff appropriately using on-call nursing management when necessary.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and dated once opened according to the manufacturer's guidelines. During observations, it was noted that several medications on two different medication carts were open and undated, making it impossible to determine their expiration dates. These included saline nasal spray, Risperidone Oral Solution, Fluticasone-salmeterol, and fluticasone nasal spray, among others. Interviews with nursing staff and the Director of Nursing confirmed that medications should be dated when opened and discarded according to the manufacturer's instructions. Additionally, a bottle of Tuberculin Purified Protein Derivative was found open, dated, and unrefrigerated, contrary to the manufacturer's storage instructions. The facility also failed to ensure that medications were stored in locked compartments. A medication cart on the Dementia Unit was observed to be unlocked and accessible without any staff present. This was confirmed by Nurse #1, who acknowledged that the cart should have been locked when unattended. These deficiencies highlight lapses in medication management and storage protocols within the facility.
Failure to Schedule Specialist Appointments for Cataract Surgery
Penalty
Summary
The facility failed to ensure that recommended specialist appointments were scheduled for three residents who had recommendations for an evaluation for cataract surgery from the consulting eye doctor. The facility's policy allows for the use of outside resources to furnish specific services to residents, but this was not followed in the cases of Residents #32, #28, and #93. Each of these residents had been recommended for cataract surgery by a consulting eye doctor, but the facility did not schedule the necessary follow-up appointments. Resident #32, admitted in December 2021, has moderate cognitive impairment and uses corrective lenses. Despite a recommendation for cataract surgery in April 2024, no follow-up was scheduled, and the resident expressed frustration over worsening vision. The resident's health care proxy was unaware of the need for a consult, and the outpatient eye doctor's office confirmed no referrals had been received. Similarly, Resident #28, who is cognitively intact, was recommended for cataract surgery in December 2024, but no follow-up was scheduled. The resident expressed difficulty in watching television and reading due to vision issues, and the outpatient office confirmed no referrals were made. Resident #93, with moderate cognitive impairment, was also recommended for cataract surgery in December 2024, but no follow-up was scheduled. The unit manager was unaware of the recommendations, and the outpatient office confirmed no referrals were received. The Director of Nurses stated that recommendations from consulting providers should be followed up within a week, but this was not done for any of the three residents, indicating a failure in the facility's process for managing specialist referrals.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for four residents, leading to several deficiencies. For one resident, the Treatment Administration Record (TAR) inaccurately documented that oxygen was running at the correct setting, that the oxygen tubing was changed as ordered, and that foam ear protectors were in place. Observations revealed that the oxygen was set at a higher level than prescribed, the tubing was not changed as documented, and foam ear protectors were not in place. Interviews with staff confirmed these discrepancies, indicating a lack of adherence to the facility's oxygen administration policy. Another resident's antipsychotic medication order lacked an associated diagnosis, contrary to the facility's policy on psychotropic medication use. The resident was receiving risperidone without a documented medical diagnosis related to its administration. Interviews with the unit manager and the Director of Nursing confirmed that the medication order should have included an associated diagnosis, highlighting a failure in medication management and documentation. Additionally, a resident with diabetes did not receive their insulin as documented in the Medication Administration Record (MAR). The nurse documented the insulin as administered at a specific time, but observations and interviews revealed that the insulin was given much later, after the resident had already eaten breakfast. This discrepancy in medication administration timing was acknowledged by the nurse and the Director of Nursing. Furthermore, another resident's blood pressure was documented as taken from the wrong arm, despite physician orders specifying the correct arm due to a dialysis shunt. The Director of Nursing suggested that the documentation error was likely due to incorrect data entry, as the resident was cognitively intact and would have advocated for themselves.
Failure to Investigate Abuse Allegations Leads to Further Resident Harm
Penalty
Summary
The facility failed to implement its abuse policy by not investigating an allegation of abuse from Resident #95, which subsequently led to the abuse of another resident by the same certified nursing aide (CNA). Resident #95, who was admitted with diagnoses including hypertension and osteoporosis, reported that a CNA handled him/her roughly during a transfer and did not provide the correct sized brief. The resident felt coerced into using a smaller brief due to the CNA's behavior. Despite the resident's report, the facility treated the incident as a grievance rather than an abuse allegation, and no thorough investigation was conducted. The facility's policy requires all allegations of abuse to be thoroughly investigated and reported to the appropriate agencies. However, the administrator categorized the incident as a customer service issue, believing it was not malicious. The administrator and Director of Nursing did not follow up adequately with Resident #95, and the incident was not documented in the medical record or reported to the state agency as required. Subsequently, another resident, Resident #1, reported being physically abused by the same CNA. The resident experienced pain and a fracture in the left ulna after the CNA forcefully pulled a laptop case handle from the resident's arm. The CNA also exhibited inappropriate behavior by refusing to assist the resident with a drink and making derogatory comments. The facility eventually suspended and terminated the CNA, but the initial failure to investigate the first allegation allowed the CNA to continue working and led to further abuse.
Failure to Report Alleged Rough Handling by CNA
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident who reported rough handling by a certified nursing aide (CNA). The resident, who was admitted with diagnoses including hypertension and osteoporosis, reported to another staff member that the CNA did not follow their preferences for transferring and pulled their arm too hard during a transfer. The resident expressed feeling safe but wanted the CNA to be trained on their transfer preferences. Despite the resident's report, the incident was not documented in the medical record or reported to the appropriate authorities as required by the facility's policy. During interviews, the resident recalled the incident, stating that the CNA was rough during a transfer to the toilet and did not provide the correct size brief, which led to the resident feeling coerced into using an inappropriate size. The administrator and the Director of Nursing (DON) both interviewed the resident, who indicated that the actions were not malicious. The administrator categorized the incident as a customer service issue rather than potential abuse, leading to the failure to report the incident to the state licensing/certification agency. The facility's policy requires immediate reporting of such allegations, but this protocol was not followed in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to implement an individualized, comprehensive care plan for a resident, specifically neglecting to use fall mats as an intervention for fall prevention. The resident, admitted with diagnoses including metabolic encephalopathy, falls, anxiety, and atrial fibrillation, was assessed to have moderate cognitive impairment and required assistance with activities of daily living. Despite the care plan indicating the need for fall mats on both sides of the bed, the resident experienced multiple falls over a period of time, with incidents recorded on several dates. Observations by the surveyor confirmed the absence of fall mats, and interviews with staff revealed a lack of awareness and implementation of this intervention. The resident's care plan, dated 11/27/24, included the use of fall mats as a preventive measure, yet the resident continued to fall, sustaining injuries such as skin tears. Interviews with the CNA, nurse, and unit manager highlighted a disconnect between the care plan and its execution, as staff were either unaware of the requirement or unable to locate the fall mats. The Director of Nursing acknowledged the resident's cognitive impairment and high risk for falls, emphasizing the necessity of implementing the care plan. This deficiency in care planning and execution was identified through observations, record reviews, and staff interviews, underscoring the facility's failure to meet the resident's needs as outlined in their care plan.
Failure to Monitor Resident's Weight Due to Broken Scale
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with congestive heart failure. The resident, who was admitted with diagnoses including chronic diastolic heart failure and generalized edema, had physician orders for daily weight monitoring to manage potential fluid buildup. However, the facility did not obtain the resident's daily weights for three consecutive days, resulting in a significant weight gain of 5.2 pounds over this period. The failure to obtain daily weights was attributed to a broken scale, which was not addressed promptly. Interviews with nursing staff revealed that the scale had been malfunctioning for some time, and there was a lack of awareness among staff and management about the issue. Despite the availability of other scales in the facility, the staff did not utilize them to fulfill the physician's orders. This oversight was not communicated effectively to the unit manager or the Director of Nursing, who were unaware of the scale's condition until after the deficiency was noted.
Failure to Obtain Physician's Order for Air Mattress Settings
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with pressure ulcers, specifically by not obtaining a physician's order for the appropriate settings of an air mattress in use. The resident, who was admitted with diagnoses including heart failure and hypotension, was observed on multiple occasions lying on an air mattress set at 175 pounds, despite their recorded weight being 148.7 pounds. The resident's care plan indicated the use of a low air loss mattress but did not specify the appropriate settings, and there was no physician's order for the air mattress settings in the resident's active orders. Interviews with facility staff, including a nurse, unit manager, and the Director of Nurses, revealed that air mattresses should be set according to the resident's weight to prevent skin breakdown. However, the resident did not have a physician's order specifying the settings, which is necessary for staff to monitor and ensure the correct settings are maintained. The resident had two unstageable deep tissue injuries, one on the heel and one on the coccyx, which were present on admission, highlighting the importance of proper mattress settings to promote healing and prevent further skin breakdown.
Failure to Maintain PICC Line Care
Penalty
Summary
The facility failed to provide proper care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, leading to a deficiency in the administration of intravenous therapy. Specifically, the facility did not change the PICC line dressing as ordered by the physician and failed to obtain weekly measurements for the external length of the PICC line to ensure it had not migrated. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy and atrial fibrillation, had a PICC line dressing that was last changed on 1/2/25, despite the requirement for it to be changed every 7 days. The deficiency was observed when a surveyor noted the outdated dressing on 1/14/25. Interviews with staff revealed that Nurse #3, a Licensed Practical Nurse, was not trained to change PICC line dressings and mistakenly believed that only Registered Nurses could perform this task. The Unit Manager confirmed that the dressing should have been changed and measurements taken, but these actions were not completed. The Director of Nursing acknowledged the requirement for dressing changes and measurements every 7 days, which were not adhered to in this case.
Failure to Adhere to Physician's Orders for Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards for a resident diagnosed with Acute Respiratory Failure with Hypoxia and shortness of breath. The resident was ordered by a physician to receive oxygen at 2L per minute via nasal cannula, with the oxygen saturation maintained above 90%. Additionally, the physician ordered the oxygen tubing to be changed weekly and foam ear protectors to be applied to the nasal cannula tubing. However, observations revealed that the resident was receiving oxygen at 3L per minute, the oxygen tubing was not changed as per the schedule, and foam ear protectors were not in place. The facility's documentation inaccurately indicated compliance with the physician's orders, noting that the oxygen was running at 2L, the tubing was changed on specified dates, and foam ear protectors were in place. However, direct observations contradicted these records, showing the resident with incorrect oxygen settings and missing foam ear protectors. Interviews with staff, including a CNA and the Unit Manager, confirmed the discrepancies, with the Unit Manager acknowledging the oversight in changing the tubing and setting the correct oxygen level. The Director of Nursing also confirmed the expectation for adherence to the physician's orders, which was not met in this case.
Deficiency in Trauma-Informed Care Planning
Penalty
Summary
The facility failed to develop a care plan for Trauma Informed Care or Post Traumatic Stress Disorder (PTSD) with resident-specific triggers and interventions for two residents. Resident #7, admitted in May 2023, had diagnoses including PTSD, depression, and anxiety. Despite having an intact cognition score of 15 out of 15 on the Minimum Data Set (MDS) assessment, the facility's Social Services Assessment inaccurately indicated that Resident #7 did not experience past trauma. The active care plan for Resident #7 included general interventions but lacked specific triggers or interventions tailored to the resident's PTSD. Resident #85, admitted in February 2024, had diagnoses including PTSD, dementia, and depression, with a severe cognitive impairment score of 6 out of 15 on the MDS assessment. The care plan for Resident #85 also lacked specific triggers or interventions, with a blank focus for PTSD. During interviews, the Social Worker acknowledged inaccuracies in the assessments and the Director of Nursing expressed expectations for resident-specific care plans, highlighting the deficiency in providing trauma-informed care tailored to the residents' needs.
Failure to Provide Dental Care for a Resident
Penalty
Summary
The facility failed to provide dental care for a resident, identified as Resident #71, who was admitted in May 2024 with diagnoses including Parkinson's Disease, malnutrition, and depression. Despite the facility's policy indicating that dental services are available for all residents requiring routine and emergency dental care, Resident #71 reported not having seen a dentist since admission. The resident expressed a desire to see a dentist to help with chewing but stated that they had not been asked if they wanted dental services. An observation by the surveyor revealed multiple missing teeth and obvious carious teeth with dark discoloration. The facility's documentation, including the Admission/Readmission Screener and the active care plan, noted missing teeth but failed to indicate the presence of carious teeth. The care plan included an intervention to coordinate arrangements for dental care, yet there was no record of the resident being seen by a dentist or being asked about dental care. During an interview, the Director of Nursing acknowledged that the resident should have had a dental consult, highlighting the facility's failure to adhere to its policy and provide necessary dental care.
Failure to Follow Up on Dental Care Recommendations
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was recommended for tooth extractions and new dentures by a consulting dentist. The resident, who has moderate cognitive impairment, was seen by a dentist in May 2024, who recommended the extraction of non-restorable teeth and the fabrication of dentures. However, there was no follow-up on these recommendations, and the resident did not receive the necessary dental care. The resident expressed concerns about missing teeth and the lack of dentures, which affected their ability to chew properly. The medical record review revealed that there were no nursing notes or follow-up information related to the dentist's recommendations. Consent forms for tooth extraction were not signed, and no appointments were scheduled with an oral surgeon. Interviews with nursing staff and the unit manager confirmed that they were unaware of the resident's need for extractions and dentures, and the process was not documented or communicated within the clinical team. The Director of Nursing acknowledged the lack of documentation and follow-up, indicating a failure in the facility's responsibility to ensure dental recommendations were reviewed and acted upon.
Failure to Implement QAPI Plan After Abuse Allegations
Penalty
Summary
The facility failed to develop a Quality Assurance Performance Improvement (QAPI) plan following two allegations of abuse against the same certified nursing aide (CNA). Two residents reported abuse by CNA #5, with one grievance filed alleging rough handling and another incident report indicating abuse. Despite these allegations, the facility did not establish a QAPI plan to address and prevent further quality of care issues, nor did it ensure the safety of residents. The facility's policy requires the identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment, and mandates the implementation of a QAPI review and analysis of such reports. The Administrator terminated CNA #5 for reasons related to customer service and insubordination, citing the CNA's body language and attitude. However, the Administrator did not recall specific phrases that led to the termination. Although the Administrator claimed to have developed a QAPI plan after the alleged abuse incident, the plan was found to be incomplete, with no further audits or plans to ensure resident safety implemented. The Administrator was unable to produce evidence of resident safety interviews during the survey, and the QAPI plan provided was blank and incomplete, with a target date set prior to the initial incident.
Failure to Implement Contact Precautions for Infected Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of contact precautions for two residents diagnosed with communicable infections. Resident #111, who was admitted with multiple diagnoses including pneumonia and chronic kidney disease, tested positive for Clostridium difficile (C. difficile). Despite the presence of a contact precaution sign on the resident's door, staff members were observed entering and exiting the room without wearing personal protective equipment (PPE) and without performing proper hand hygiene. This included instances where staff members handled items and interacted with other residents without adhering to the necessary infection control protocols. Similarly, Resident #2i, who was admitted with conditions such as phantom limb syndrome and morbid obesity, was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the elbow. The resident's care plan indicated the need for enhanced barrier precautions, yet there was no signage or PPE cart outside the resident's room to indicate the required contact precautions. The infection preventionist was unaware of the resident's MRSA status, and the necessary precautions were not implemented, leaving the resident and others at risk of infection transmission. Interviews with the Director of Nursing (DON), the Administrator, and other staff members revealed a lack of adherence to infection control guidelines. The DON acknowledged that contact precautions should have been in place for both residents, and staff were expected to follow infection control protocols. However, observations indicated a systemic failure to implement these precautions, as staff continued to neglect the use of PPE and proper hand hygiene, thereby compromising the facility's infection control efforts.
Failure to Offer COVID-19 Vaccine During New Hire Orientation
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to two employees during their new hire orientation, which was a requirement according to the facility's policy. The policy, titled 'Employee Infection and Vaccination Status,' mandates that employees be assessed for vaccination status against infectious conditions prior to or upon their duty assignment. It also requires that employees be current with mandated vaccinations before performing direct resident care. Despite these requirements, the facility did not offer the COVID-19 vaccine to Nurse #3 and Activities Assistant #1 during their orientation sessions. The Director of Nurses confirmed that both employees were provided with informed consent forms and educated on the COVID-19 vaccination side effects, but they refused the vaccination. However, the forms were not properly completed, as Nurse #3 did not date the form. The Human Resources Manager confirmed the dates of the new hire orientations for both employees, indicating that the oversight occurred during these sessions. The Administrator acknowledged that both employees have been working in the facility since their orientation, highlighting the lapse in following the facility's vaccination policy during the onboarding process.
Inaccurate MDS Coding for Dental and Feeding Tube Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #71, who was admitted with diagnoses including Parkinson's, malnutrition, and depression, was inaccurately coded on the MDS regarding dental status. Despite having multiple missing and carious teeth, the MDS indicated no obvious broken or carious teeth. This discrepancy was confirmed during an interview with the resident, who expressed a desire to see a dentist to help with chewing, and was further corroborated by the Director of Nursing, who acknowledged the MDS should reflect the resident's actual dental condition. For Resident #47, who was admitted with conditions such as chronic obstructive pulmonary disease, tracheostomy status, paranoid schizophrenia, anxiety, and dysphagia, the MDS failed to code the presence of a feeding tube. The resident's plan of care included enteral tube feeding, yet the MDS inaccurately indicated no feeding tube was present. This error was acknowledged by the MDS Nurse and the Director of Nursing, who stated that the MDS should be coded according to the Resident Assessment Instrument (RAI) manual.
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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