Ayer Valley Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Ayer, Massachusetts.
- Location
- 400 Groton Road, Ayer, Massachusetts 01432
- CMS Provider Number
- 225421
- Inspections on file
- 31
- Latest survey
- March 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ayer Valley Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to provide safe and appropriate respiratory care for five residents, including not ensuring proper equipment and physician orders for CPAP therapy, not maintaining humidified oxygen as ordered for two residents, providing oxygen therapy without a current physician order for one resident, and not properly labeling or cleaning oxygen equipment for another resident. Staff were observed to be unfamiliar with respiratory equipment and did not follow facility policies for respiratory care.
The facility did not ensure that a physician reviewed and acted upon consultant pharmacist recommendations for two residents, resulting in one resident not receiving routine Dilantin level monitoring and developing toxicity, and another resident not having orders updated to instruct mouth rinsing after inhaler use to prevent oral thrush. The process for communicating and implementing pharmacy recommendations was not followed as required by facility policy.
Five residents with dementia did not receive physician visits at the required intervals, with significant lapses between scheduled visits. Clinical records and practitioner notes confirmed that the mandated alternating 60-day visits between the physician and NP were not maintained, as acknowledged by facility staff.
Three nurses, including the ADON and SDC, did not have the necessary skills or training to provide proper CPAP therapy with oxygen for a resident with COPD. Despite physician orders, staff could not identify the machine type, connect oxygen, or set correct pressures, resulting in the resident not receiving prescribed respiratory care.
A CNA's annual performance review was not completed as required, as the review form lacked the employee's signature and there was no evidence the review was discussed with the CNA. Interviews with HR and nursing leadership confirmed the deficiency, and attempts to contact the CNA for clarification were unsuccessful.
Staff failed to consistently follow Enhanced Barrier Precautions during high-contact care activities for two residents with indwelling medical devices, including a urinary catheter and a gastrostomy tube. Observations showed that required PPE such as gowns and gloves were not used during care, and EBP signage and supplies were missing or not utilized, despite staff awareness of facility policy.
A resident with a history of hypertension, CVA, and dementia, who had previously received PCV13, was not offered an updated pneumococcal vaccine (PCV20 or PCV21) as required by CDC guidelines. The resident's record lacked documentation of vaccine offer, education, or contraindication, despite facility policy requiring these steps.
Three residents with significant medical histories were not offered or documented as having been offered the updated 2024-2025 COVID-19 vaccine, despite facility policy requiring this for all eligible individuals. Record review and staff interviews confirmed the absence of documentation for vaccine offers, refusals, or contraindications.
A resident with atrial fibrillation and severe cognitive impairment did not receive a scheduled dose of Warfarin or the required PT/INR lab monitoring as ordered by the physician. Facility staff failed to notify the physician promptly or complete a medication error report, and the resident's lab results were found to be subtherapeutic following the missed doses.
Surveyors found that hot foods and cold drinks were not served at appropriate temperatures, with test trays showing lukewarm or cool food and beverages above recommended cold temperatures. Delays in meal delivery, understaffing in the kitchen, and the use of open carts contributed to the problem. Multiple residents and staff reported ongoing complaints about cold, unappetizing meals, and facility records confirmed these issues.
A resident with dementia and dysphagia, who was prescribed a nectar/mildly thickened liquid diet due to aspiration risk, was served coffee at breakfast that was not thickened to the required consistency. While other beverages were properly thickened, the coffee remained thin, and staff acknowledged the error during surveyor observation and interviews.
A resident with dementia experienced significant unintended weight loss and was referred for a speech-language pathology (SLP) evaluation after difficulty eating was identified. Despite facility policy requiring timely rehabilitation services, the resident was not seen by the SLP within the expected timeframe, and documentation confirmed the evaluation had not occurred following the referral.
Staff failed to accurately document the administration of CPAP therapy for a resident with COPD and severe cognitive impairment. Although records showed the therapy was provided nightly as ordered, interviews and review revealed that the CPAP was not consistently administered, refusals were not documented, and the physician was not notified as required by policy.
A resident with PTSD and Bipolar Disorder did not receive a trauma assessment or a comprehensive trauma-informed care plan upon admission, despite exhibiting behavioral symptoms and facility policy requiring such assessments. The care plan was not updated to include trauma-informed interventions until the time of survey, and staff confirmed the assessment was missed.
A resident with a Full Code status was found unresponsive and, after unsuccessful CPR by staff and EMS, was pronounced dead by a hospital physician contacted by EMS. Although the resident's family and the DON were notified, the resident's physician was not informed of the death as required by facility policy. The nurse on duty was unsure of the requirement to notify the physician, and documentation of physician notification was absent.
A resident with severe cognitive impairment and communication needs reported missing hearing aids, but the facility did not document or initiate the grievance process as required. Despite repeated reports from the resident, their representative, and a nurse practitioner, the concern remained unresolved and no formal grievance was documented or investigated.
A resident with diabetes and cognitive impairment received IV antibiotics via a midline catheter, but the facility failed to obtain physician orders for the catheter's care and maintenance, and there was no documentation that required care such as site monitoring, dressing changes, or flushing was performed, as required by facility policy.
The facility did not have a valid written transfer agreement with a Medicare or Medicaid-certified hospital for several months after the closure of its previous partner hospital, and was unable to provide evidence of any active agreement during that time.
The facility failed to notify physicians of significant weight loss in three residents, as required by policy. One resident lost 14 pounds in December, another lost 9 pounds between July and August, and a third lost 19 pounds between August and September. The lack of documentation and notification was confirmed by staff interviews.
A resident with chronic edema experienced a significant weight loss, yet a nurse reduced the frequency of weight monitoring without obtaining a physician's order, contrary to facility policy. The MDS nurse wrote a verbal order following a clinical meeting decision, but the physician was not consulted, and the resident's recent weight loss was not considered.
The facility failed to ensure proper nutritional assessment and monitoring for three residents at risk for altered nutritional status, leading to significant weight loss. One resident experienced a notable weight loss over a two-week period without physician or dietician notification, nor were new interventions implemented. Another resident's significant weight loss was not addressed in a timely manner, delaying necessary interventions. A third resident also suffered from significant weight loss without proper notification or intervention. The facility's lack of consistent dietician involvement and communication contributed to the failure to address the residents' nutritional needs effectively.
A facility failed to maintain adequate staffing levels on the North 2 Unit, leading to delays in resident care and compromised meal service. A resident with severe cognitive impairment experienced significant delays in receiving incontinence care due to understaffing. Additionally, meals were served at inappropriate temperatures, as staff struggled to manage multiple tasks due to the shortage of CNAs.
A facility failed to implement its QAPI plan effectively, resulting in staffing deficiencies. Interviews and observations revealed that the facility consistently had fewer CNAs than required, leading to inadequate care for residents. A resident was found in soiled bedding due to delayed care, and meal service was significantly delayed. The facility's assessment indicated a need for more CNAs and RNs than were employed, and the required audits of staff-to-resident ratios were not conducted.
A resident with paraplegia, requiring a Hoyer lift and two staff members for transfers, was transferred by a CNA without assistance, contrary to the care plan. The CNA cited staff shortages as the reason for acting alone. The resident confirmed that transfers sometimes involved only one staff member, and the DON was unaware of such practices.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services consistent with professional standards of practice for five residents. For one resident with COPD and sleep apnea, the facility did not ensure the resident had the correct oxygen adaptor for their CPAP machine, resulting in the resident not receiving CPAP therapy as required. Additionally, there was no physician's order specifying the required CPAP settings, and staff were observed to be unfamiliar with the equipment, unable to identify whether it was a CPAP or BIPAP machine, or how to connect oxygen to it. The resident and their representative both reported that the CPAP machine was not being used as needed, and staff interviews confirmed a lack of knowledge and follow-through regarding the resident's respiratory care needs. Two other residents receiving oxygen therapy via concentrator were found to have empty humidifier bottles attached to their oxygen equipment, despite orders for humidified oxygen. The humidifier bottles were either undated or not replaced as required, and staff acknowledged that the bottles should have been replaced but were not. This failure to maintain proper humidification for oxygen therapy was observed on multiple occasions for both residents. Another resident was observed receiving oxygen therapy without a current physician's order, as the order for oxygen had been discontinued, but the resident continued to receive oxygen. Staff were unaware that the oxygen had been discontinued and continued to provide the therapy. For a fifth resident, the facility failed to ensure that oxygen tubing was dated and labeled, and the oxygen concentrator filter was not cleaned as required, with visible dust observed on the filter. Staff interviews confirmed that the tubing and filters were not maintained according to policy, and staff could not verify when the tubing was last changed.
Failure to Act on Consultant Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were reviewed and acted upon by the Physician for two residents. For one resident with epilepsy and other neurological diagnoses, the Consultant Pharmacist recommended routine monitoring of serum Dilantin levels every six months. This recommendation, documented in the MRR, was not implemented, and there were no ongoing physician orders to obtain serum Dilantin levels. The resident had not had a Dilantin level checked since admission, and subsequently developed a critically high Dilantin level, resulting in cognitive decline, altered mental status, and hospitalization for Dilantin toxicity. Interviews revealed that the recommendation was not communicated to or acted upon by the physician, and the Director of Nursing (DON) and other staff were unaware of why the recommendation was not followed. For another resident with chronic obstructive pulmonary disease (COPD) receiving Breztri inhaler therapy, the Consultant Pharmacist made recommendations on two separate occasions to update the physician's order to instruct the resident to rinse their mouth after inhaler use to prevent oral thrush. These recommendations were documented but not reviewed or implemented by the physician, and the resident's medical record did not reflect any update to the orders. Nursing staff described their process for administering inhalers but did not mention instructing the resident to rinse their mouth, and interviews with the DON and other staff confirmed that the pharmacy recommendations should have been added to the resident's orders but were not. The facility's policy requires that the Consultant Pharmacist's recommendations be communicated in writing, reviewed by the DON, and forwarded to the primary provider for action. However, in both cases, the process failed, resulting in the physician not reviewing or acting on the pharmacist's recommendations. This lapse led to a lack of appropriate monitoring and preventive care for the affected residents.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents received physician visits at the required frequency, as mandated for long-term care settings. Specifically, five residents with dementia were not seen by a physician within the required intervals. For each of these residents, there were significant gaps between physician visits, ranging from 112 to 183 days, which exceeded the expected schedule for alternating routine 60-day visits between the physician and the nurse practitioner (NP). Record reviews confirmed that the affected residents were not seen by a physician during the required timeframes, and this was acknowledged by the Corporate Nurse during an interview with the surveyor. The deficiency was identified through a review of clinical records and practitioner notes, which showed that the required physician visits did not occur as scheduled for these residents.
Failure to Ensure Staff Competency in CPAP/Oxygen Therapy
Penalty
Summary
Three licensed nurses, including a staff nurse, the Assistant Director of Nursing (ADON), and the Staff Development Coordinator (SDC), lacked the necessary competencies and skills to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) who required CPAP therapy with supplemental oxygen. Despite physician orders specifying the use of a CPAP machine with oxygen at 2 liters per minute and particular pressure settings, the nursing staff were unable to identify the type of machine (CPAP or BIPAP), did not know how to connect oxygen to the device, and were unaware of the correct pressure settings. The resident and their representative both reported that the resident was not receiving the prescribed CPAP therapy due to the staff's lack of knowledge and the absence of the required adaptor to connect oxygen to the machine. Interviews with the involved nurses revealed that none had been assessed for competency in the use of CPAP or BIPAP machines, and the SDC acknowledged that staff should have been trained and assessed for competency when the resident was ordered to use the CPAP device. The facility's own assessment indicated that it provided respiratory care, including CPAP/BIPAP therapy, and was responsible for ensuring staff competency in these areas. However, the failure to provide necessary training and competency assessments resulted in the resident being unable to use the CPAP machine as ordered.
Annual Performance Review Not Completed for CNA
Penalty
Summary
The facility failed to complete an annual performance review for one Certified Nurses Aide (CNA) who had been employed for more than 12 months. According to the facility's Performance Appraisal Policy, employees are required to receive annual performance appraisals, which must be reviewed with the employee, signed by the employee to acknowledge the review, and then filed in the personnel file. For the CNA in question, although a performance review form was dated and present in the file, the employee signature line was left blank, indicating the review was not discussed with the CNA as required. Interviews with the Human Resources Director confirmed that the process for annual performance reviews includes tracking due dates, providing forms to department directors, and ensuring reviews are completed and signed. The Director of Nursing also confirmed there was no evidence that the performance review was ever reviewed with the CNA. Attempts to contact the CNA for further clarification were unsuccessful, as the CNA did not answer the phone and the voicemail box was full.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents, resulting in lapses in the use of Enhanced Barrier Precautions (EBP) during high-contact care activities. For one resident with a history of urinary tract infection, neurogenic bladder, and an indwelling urinary catheter, staff did not follow EBP protocols. Observations revealed the absence of EBP signage, PPE supplies, and waste receptacles in or near the resident's room. Multiple staff members, including a physician, a staff development coordinator, and a nurse, entered the resident's room and provided care without donning the required gown and gloves. The nurse who provided urinary catheter care wore gloves but did not use a gown, and neither the staff development coordinator nor the nurse performed hand hygiene after exiting the room. Interviews confirmed that staff were aware of the EBP requirements but failed to comply during care activities. Another resident, who was severely cognitively impaired and dependent on a gastrostomy tube for enteral feeding, was also not provided care in accordance with EBP protocols. During a medication administration procedure via the resident's G-tube, a nurse donned gloves but did not wear a gown, despite EBP signage and available PPE supplies outside the room. The nurse acknowledged that a gown was required for this high-contact care activity and admitted to not following the protocol. The staff development coordinator and infection preventionist both confirmed that staff had been educated on the need to use gowns and gloves for device care and other high-contact activities for residents on EBP. The deficiencies were identified through direct observation, interviews with staff and residents, and review of facility policies and resident care plans. The facility's own policy required the use of gowns and gloves for high-contact care activities involving indwelling medical devices, such as urinary catheters and feeding tubes, regardless of the resident's MDRO status. Despite these clear policies and staff awareness, the required infection prevention measures were not consistently implemented, as evidenced by the surveyor's findings.
Failure to Offer Up-to-Date Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer an up-to-date pneumococcal vaccine to a resident who was eligible according to CDC guidelines. The resident, who was over the age of [AGE] and had a medical history including hypertension, cerebrovascular accident (CVA), and dementia, had received a dose of PCV13 in 2015 but had not received any subsequent pneumococcal vaccines, such as PCV20 or PCV21, as recommended by current CDC guidance. There was no documentation in the clinical record indicating that the vaccine was contraindicated for this resident. A review of the facility's pneumococcal vaccination policy confirmed that all admitted residents should be offered the vaccine in accordance with CDC recommendations, and that education and consent should be documented. However, the resident's record did not show evidence of being offered the updated vaccine, nor was there documentation of education or consent related to the pneumococcal immunization after admission. This deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged the lack of evidence that the updated vaccine had been offered.
Failure to Offer and Document Updated COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer and document updated 2024-2025 COVID-19 immunizations for three residents who were not up to date with their vaccinations and did not have documented contraindications. According to the facility's COVID-19 Vaccination Policy, all residents are to be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and this offer, along with any refusals or contraindications, must be documented in the resident's medical record. Review of the clinical records for three residents revealed that each had received their most recent COVID-19 vaccine in 2022 or 2023, but there was no evidence that the updated 2024-2025 vaccine had been offered or that any contraindication was documented. Interviews with the DON and Corporate Nurse confirmed that the facility's policy requires offering the updated vaccine and documenting any declinations or contraindications, but there was no evidence this had occurred for the three residents in question. The residents involved had significant medical histories, including dementia, cancer, chronic lung disease, diabetes mellitus, and hypertension, and were all of advanced age. The lack of documentation and failure to offer the updated vaccine was identified through record review and staff interviews.
Failure to Administer Anticoagulant and Complete Required Lab Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, cerebrovascular accident, hypertension, and metabolic encephalopathy did not receive Warfarin Sodium, an anticoagulant medication, as ordered by the physician. The resident was severely cognitively impaired and was dependent on staff for medication administration and monitoring. The medication administration record showed that the Warfarin dose scheduled for one day was not administered, and the corresponding PT/INR laboratory tests, which are essential for monitoring the effectiveness and safety of anticoagulant therapy, were not completed as ordered. Facility policies required that medications be administered as ordered, and that any missed doses or medication errors be documented, reported to the physician, and followed up with a medication error report and risk management process. In this case, there was no evidence that the physician was notified promptly when the Warfarin dose was missed, nor was there documentation of a medication error report being completed. Interviews with staff confirmed that the missed dose and lab draws were not reported according to policy, and the Director of Nursing acknowledged that the required documentation and reporting did not occur. The resident's PT/INR levels were found to be subtherapeutic after the missed doses, as indicated by lab results and clinical notes. The failure to administer the medication and complete the required laboratory monitoring as ordered by the physician constituted a significant medication error. The facility did not follow its own protocols for medication administration, error reporting, and anticoagulant therapy monitoring, leading to the identified deficiency.
Failure to Serve Food and Drink at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures to residents on two units, as evidenced by direct observations, interviews, and record reviews. Food intended to be served hot was found to be lukewarm or cool, and drinks intended to be cold were not at appropriate temperatures. Test trays on the North One and South Two Units revealed that hot foods such as eggs, ham, and oatmeal were served at temperatures ranging from 98°F to 121°F, which is below the required standard for hot food. Cold beverages, including milk and orange juice, were measured at 52°F, which is above the recommended temperature for cold drinks. Residents and staff consistently reported that food was often cold and unappetizing, with complaints documented in Food Committee and Resident Council meeting minutes. The deficiency was further compounded by operational issues in the kitchen and meal delivery process. The kitchen was understaffed, with only two dietary aides present instead of the usual three, leading to delays in meal preparation and tray line start times. Meal carts were filled and delivered to the units significantly later than scheduled, with some carts being open rack-style rather than enclosed, which contributed to the inability to maintain proper food temperatures during transport. Staff interviews confirmed that the use of open carts and delays in meal delivery were ongoing issues, and that residents, particularly those on the South Two Unit, were frequently the last to receive their meals, increasing the likelihood of receiving cold food. Residents directly affected by this deficiency reported dissatisfaction with the temperature and quality of their meals. Two residents on the South Two Unit specifically stated that their breakfasts were cold, consistent with the findings from test trays and staff interviews. Staff also noted that food quality had declined and that resident complaints about cold food were common and longstanding. The facility's own policies required that food be served at safe and appetizing temperatures, and that meal distribution be timely and protect against temperature loss, but these standards were not met during the survey period.
Failure to Provide Prescribed Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident with dysphagia and dementia. The resident had a physician's order and care plan specifying a dysphagia-advanced diet with nectar/mildly thickened liquids due to an identified risk of aspiration. During a breakfast meal observation, it was found that while the orange juice and milk provided to the resident were appropriately thickened, the coffee was not. The coffee was observed to be of thin consistency, which did not meet the prescribed nectar/mildly thick standard. The CNA responsible for the resident's care acknowledged that the coffee had not been thickened as required and confirmed her understanding of the correct consistency needed for the resident's safety. Interviews with facility staff, including the CNA and the unit manager, confirmed that the resident required thickened liquids and that the failure to thicken the coffee could result in the resident receiving an unsafe liquid consistency. The CNA reported that she typically thickens the coffee herself using a provided thickening agent, but on this occasion, the coffee was not thickened to the required consistency. The unit manager also confirmed the resident's need for nectar/mildly thick liquids and the potential for aspiration if the liquids are not properly thickened.
Failure to Provide Timely Speech-Language Therapy Evaluation After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services as required for a resident with dementia who experienced significant unintended weight loss. The resident was admitted with a diagnosis of dementia and was noted to have difficulty eating. Over a three-month period, the resident lost 8.05% of body weight, as documented in the electronic medical record. On a specified date, the registered dietician identified the unintended weight loss and implemented nutrition interventions, including a referral to a speech-language pathologist (SLP) and a downgrade of meal texture to dysphagia advanced, pending the SLP evaluation. Despite the referral made by the registered dietician, the resident was not seen by the SLP in a timely manner. Facility policy required that rehabilitation services, including speech-language therapy, be delivered by qualified staff and that referrals be addressed within 72 hours. However, interviews with the Rehabilitation Director confirmed that the resident had not been evaluated by the SLP as of the time of the survey, even though the referral had been made several weeks prior. Documentation in the medical record also showed no evidence of an SLP assessment following the referral.
Failure to Accurately Document and Administer CPAP Therapy
Penalty
Summary
Facility staff failed to maintain accurate medical records regarding the administration of Continuous Positive Airway Pressure (CPAP) therapy for a resident with chronic obstructive pulmonary disease (COPD) and severe cognitive impairment. Although physician orders required nightly CPAP use with specific settings and documentation, the treatment administration records (TARs) indicated that nurses consistently documented the therapy as administered, even when it was not provided. Interviews with the resident and their representative confirmed that the CPAP machine was not used nightly as ordered, and the necessary equipment to connect oxygen to the CPAP was not supplied. The resident reported repeatedly asking staff about the CPAP, and the representative was aware of the lack of therapy. Further review revealed that nursing staff did not document resident refusals or reasons for not administering the CPAP, as required by facility policy. Instead, they signed off on the TAR as if the therapy had been given. The clinical nurse support staff confirmed that three night shift nurses reported the resident refused the CPAP, but none documented these refusals or notified the physician, contrary to policy. This resulted in inaccurate medical records and a failure to follow established documentation and notification procedures.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for one resident who had a documented history of Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder. Despite the facility's policy requiring trauma assessments upon admission and the development of trauma-informed care plans when applicable, the required assessment was not completed for this resident. The resident's behavioral health notes and Minimum Data Set (MDS) assessment confirmed the diagnoses of PTSD and Bipolar Disorder, as well as the presence of behavioral symptoms such as verbal and physical outbursts directed at others. A review of the resident's care plan revealed that no trauma-informed care plan was documented until the time of the facility survey, several months after admission. During an interview, the facility's social worker acknowledged that a trauma assessment should have been completed at admission and that this step was missed for the resident in question.
Failure to Notify Physician of Resident Death
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically the resident's death, as required by facility policy. The resident, who had a diagnosis of hypertension and was designated as Full Code with a Medical Order for Life-Sustaining Treatment (MOLST) to attempt resuscitation, was found unresponsive without a pulse or breath sounds. Facility staff initiated CPR and activated EMS, who continued resuscitation efforts and subsequently contacted a hospital physician to pronounce the resident deceased. The nursing progress notes indicated that the resident's family and the Director of Nursing (DON) were notified, but there was no documentation that the resident's physician was informed of the death. Nurse #6, who was on duty at the time, stated during interview that she did not notify the resident's physician, as she was unsure if it was required. The DON confirmed that the nurse should have contacted the physician or on-call provider to report the death. Additionally, a review of the resident's records showed that an order for RN pronouncement and release to the funeral home was not entered until after the death had occurred, and the corporate nurse acknowledged this was done upon later review when it was discovered the order was missing. The facility's policies clearly required physician notification in the event of a resident's death, but this was not carried out in this instance.
Failure to Timely Resolve Grievance Regarding Missing Hearing Aids
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for one resident who was missing hearing aids. The resident, who had severe cognitive impairment and was usually understood, reported the missing hearing aids to staff, but did not receive a response. The resident's representative also reported the missing hearing aids to facility staff approximately four months prior to the survey, but did not receive any follow-up or resolution. Additionally, a nurse practitioner documented the ongoing issue in a progress note and followed up with the nursing manager and social worker, who indicated that a grievance would be initiated. Despite these reports, the social worker acknowledged during an interview that she was aware of the concern but had not documented a formal grievance, had not followed the grievance process, and the issue remained unresolved. The facility's policy required that grievances be documented, investigated, and resolved within specific timeframes, with follow-up to the resident and their representative. However, these steps were not taken, and the resident's concern about the missing hearing aids was not addressed according to policy.
Failure to Obtain Orders and Document Care for Midline Catheter
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident who required a midline catheter for intravenous (IV) antibiotic therapy. After returning from the emergency room with a midline catheter placed in the right upper arm, the resident did not have any physician orders for the care and maintenance of the catheter, such as site monitoring, dressing changes, or flushing protocols. The facility's own policy required specific actions for midline catheter care, including flushing with preservative-free 0.9% sodium chloride, dressing changes at least every seven days or when compromised, visual inspection every four hours, and documentation of all procedures in the Treatment Administration Record (TAR). Record review showed that while the resident received the ordered IV antibiotics, there was no documentation in the Medication Administration Records (MARs) or TARs indicating that any care or maintenance of the midline catheter was performed. The unit manager confirmed that no physician orders were in place for the catheter's care and could not provide evidence that required care and services were provided. The resident was cognitively impaired and had a history of diabetes mellitus type II with diabetic neuropathy at the time of the deficiency.
Failure to Maintain Current Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain an up-to-date written transfer agreement with a hospital certified by Medicare or Medicaid, as required. The existing agreement was with a local hospital that had closed, and the facility did not have a valid transfer agreement in place from the time of the hospital's closure until a new agreement was established several months later. During this period, the facility was unable to provide evidence of any active transfer agreement, as confirmed by the administrator during an interview and review of facility records.
Failure to Notify Physicians of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physicians of three residents who experienced significant weight loss, as required by the facility's policy. Resident #3, who was admitted with diagnoses including hypertension and chronic edema, lost 14 pounds between December 9 and December 23, 2024. Despite the policy requiring notification of weight changes greater than 3 pounds in three days or 5 pounds in seven days, there was no documentation that the physician was informed of this weight loss or the resident's refusals to be weighed. Interviews with the unit manager and the physician confirmed that the physician was not notified. Resident #2, diagnosed with unspecified dementia and diabetes mellitus, experienced a 9-pound weight loss between July and August 2024. The facility's records did not show that the physician or registered dietician (RD) were notified of this weight loss. A dietary progress note from September 2024 indicated a significant weight loss, and a recommendation for a nutritional supplement was made. However, the lack of timely notification to the physician and RD was confirmed by the unit manager. Resident #1, with diagnoses of unspecified dementia and anemia, lost 19 pounds between August and September 2024. The facility's records lacked documentation of notification to the physician or RD regarding this significant weight loss. A nutrition progress note from November 2024 highlighted the weight loss, and a new order for nutritional shakes was made. The director of nurses acknowledged the failure to notify the physician and RD in a timely manner, as per the facility's policy.
Failure to Obtain Physician's Order for Weight Monitoring Change
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for a resident with chronic edema. A nurse wrote a verbal order to decrease the frequency of the resident's weight monitoring without obtaining a physician's order, as required. The facility's policy mandates that all orders must be provided by licensed practitioners authorized to prescribe such orders. The resident's medication administration record indicated a significant weight loss, yet the frequency of weight monitoring was reduced without proper authorization. During a clinical meeting, it was decided to decrease the resident's weight monitoring frequency from three times per week to weekly, but the resident's recent significant weight loss was not reviewed. The MDS nurse admitted to writing the verbal order without consulting the physician. The physician confirmed that he was not notified of the resident's weight change and did not authorize the change in monitoring frequency. The Director of Nurses stated that nurses are expected to communicate with a physician before writing a verbal order.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper nutritional assessment and monitoring for three residents at risk for altered nutritional status, leading to significant weight loss. Resident #3 experienced a notable weight loss from 170.6 lbs to 156.6 lbs over a two-week period, yet there was no documentation of physician or dietician notification, nor were new interventions implemented. The resident's care plan had not been updated since March 2024, despite ongoing weight loss. Resident #2 experienced a significant weight loss from 187.3 lbs in July 2024 to 162.8 lbs in September 2024. Although the Registered Dietician recommended a nutritional supplement, it was not administered as prescribed. The facility failed to notify the physician and dietician of the weight loss in a timely manner, delaying the implementation of necessary interventions. Resident #1 also suffered from significant weight loss, dropping from 137.4 lbs in July 2024 to 116.2 lbs in September 2024. There was no evidence that the physician or dietician were informed of this weight loss, and no new interventions were developed. The facility's lack of consistent dietician involvement and communication contributed to the failure to address the residents' nutritional needs effectively.
Staffing Shortages Lead to Delayed Care and Cold Meals
Penalty
Summary
The facility failed to maintain adequate staffing levels, particularly on the North 2 Unit, which led to delays in resident care and compromised meal service. The facility was licensed for 123 beds, with 41 beds on the North 2 Unit, but employed significantly fewer Certified Nurse Aides (CNAs) and Registered Nurses (RNs) than required by their own Facility Assessment. Observations and interviews revealed that the unit was often staffed with fewer CNAs than the staffing goals required, leading to delays in responding to call lights and providing necessary care. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced significant delays in receiving incontinence care. On multiple occasions, the resident's family member found them in soiled conditions and had to wait extended periods for assistance after activating the call light. Interviews with staff confirmed that the unit was frequently understaffed, making it difficult to provide timely care to all residents, especially those requiring two staff members for assistance. Additionally, the facility failed to serve meals at appropriate temperatures, as observed during a breakfast service on the North 2 Unit. The meal service was delayed, resulting in food being served at temperatures below the facility's standards for palatability and safety. Staff interviews indicated that the shortage of CNAs contributed to the delay in meal service, as they struggled to manage multiple tasks simultaneously, such as getting residents up and passing breakfast trays.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to implement its Quality Assurance Performance Improvement (QAPI) plan effectively, particularly in monitoring and assessing staffing levels. The facility's policy, revised in November 2019, required an ongoing program to evaluate and improve the quality of resident care. However, during a survey conducted in March 2024, the Department of Public Health cited the facility for failing to comply with staffing requirements, as outlined in their Plan of Correction. The facility was supposed to have four Certified Nurse Aides (CNAs) on both day and evening shifts, but consistently fell short of this number, leading to inadequate care for residents. Interviews with staff and family members revealed significant issues related to staffing shortages. A family member reported that a resident was found in soiled bedding on two occasions, and staff attributed the delay in care to being short-staffed. Nurses and CNAs confirmed that they often worked with fewer staff than required, making it difficult to provide timely care, especially in a secured unit where many residents required assistance from two staff members. Observations by the surveyor noted that meal service was delayed, taking over 45 minutes to complete, contrary to the Director of Nurses' expectation of 10-15 minutes. The facility's assessment indicated a need for 29 full-time CNAs and 8 full-time Registered Nurses (RNs), but they employed only 11 CNAs and 4 RNs. The Schedule Coordinator did not consider a unit short-staffed unless there was only one CNA on duty, which contributed to the ongoing staffing issues. The Administrator acknowledged the staffing challenges and the reliance on agency staff, but also admitted that the required audits of staff-to-resident ratios had not been conducted as planned.
Failure to Follow Care Plan for Hoyer Lift Transfers
Penalty
Summary
The facility failed to consistently implement and follow the care plan for a resident who required the use of a Hoyer lift with the assistance of two staff members for all transfers. On a specific date, a Certified Nurse Aide (CNA) transferred the resident from their bed into a wheelchair using a Hoyer lift without the assistance of another staff member, contrary to the care plan's requirements. This incident was observed by a surveyor during a unit tour, where the resident was seen suspended in the air above the wheelchair in the Hoyer lift sling, with only one CNA present. The resident, who was admitted to the facility in January 2024 with a diagnosis of paraplegia, was assessed as cognitively intact and dependent on staff for all transfers. The care plan and Care Kardex both indicated the need for two staff members during transfers. During interviews, the CNA admitted to transferring the resident alone due to a lack of available staff, and the resident confirmed that sometimes only one staff member assisted during transfers. The Director of Nurses stated that she was unaware of any instances where a Hoyer lift was used with less than two staff members and emphasized that staff were expected to follow the care plans.
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 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.
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.
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.
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.
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 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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