Baker-katz Skilled Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 194 Boardman Street, Haverhill, Massachusetts 01830
- CMS Provider Number
- 225743
- Inspections on file
- 16
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Baker-katz Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Two residents at high risk for pressure ulcers did not receive timely and appropriate care as ordered. One resident's blister was not promptly assessed or treated, and documentation was incomplete. Another resident did not have prescribed interventions such as offloading, air boots, and lambswool consistently applied, despite having active skin issues. Staff interviews confirmed that physician orders and care plans were not consistently followed, and required documentation was lacking.
Staff did not change oxygen and nebulizer tubing weekly as ordered for two residents requiring respiratory care, resulting in the use of outdated equipment despite clear physician orders and facility policy. Observations and staff interviews confirmed that tubing was not replaced on schedule for residents dependent on oxygen and nebulizer therapy.
Surveyors observed treatment carts containing prescription ointments, creams, and other supplies left unlocked and unattended in two halls, with multiple staff and residents passing by. Facility policy and staff interviews confirmed that carts should be locked unless a nurse is present, but this was not followed.
Housekeeping staff failed to follow infection control protocols by not performing hand hygiene after removing gloves and before donning new gloves, and by wearing potentially contaminated gloves between resident rooms and in hallways. These actions were observed multiple times and confirmed by interviews with staff and management, indicating a breakdown in adherence to the facility's infection prevention policies.
A resident experienced an unwitnessed fall, and the assigned nurse failed to report the incident to the physician, guardian, DON, or oncoming nurse, as required by facility policy. The resident, with a history of falls and multiple medical conditions, was later found to have rib fractures and sepsis at the hospital. The incident was not documented in the resident's medical record, and the facility's protocol for reporting and documenting such incidents was not followed.
A resident with multiple health conditions experienced an unwitnessed fall in an LTC facility. Although a nurse claimed to have assessed the resident, there was no documentation to support this. The resident was later found to have rib fractures and sepsis at the hospital. The facility failed to follow its policy on resident assessment and incident reporting, and the incident was not communicated to administration until the resident's condition worsened.
The facility failed to implement physician-ordered TED hose for a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and hypertension. Observations and staff interviews revealed that the nursing staff was unaware of the order, leading to non-compliance with the resident's care plan.
The facility failed to develop individualized trauma-informed care plans for two residents with PTSD, resulting in generic care plans that did not identify specific triggers for retraumatization or preferences for female caregivers. The deficiencies were identified during a survey, and the care plans were only updated after the surveyor's interviews with the social worker and DON.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who were assessed to be at high risk for developing pressure ulcers. For one resident with multiple sclerosis and significant immobility, a blister was identified on the ankle by staff, but there was no immediate skin assessment, no timely implementation of a physician's order for treatment, and incomplete documentation regarding the wound's characteristics and progress. The weekly skin check was not performed as scheduled, and the treatment order for the blister was not implemented until five days after the area was first identified. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the required documentation and monitoring were lacking. For another resident with dementia, a history of pressure ulcers, and severe cognitive impairment, the facility did not ensure that the care plan and physician's orders related to skin integrity were implemented. Observations revealed that the resident's feet and heels were not offloaded as ordered, and prescribed interventions such as air boots, foam dressings, and lambswool between all toes were not consistently in place. The resident was observed with blood blisters and redness on the feet and toes, and there was no documentation of treatment refusal. Staff interviews confirmed that the physician's orders were not being followed, and the resident's care plan interventions were not consistently implemented. The facility's own policy required systematic skin inspections, prompt assessment and intervention for skin issues, and thorough documentation of wound characteristics and progress. In both cases, there were failures to adhere to these protocols, including missed assessments, delayed or omitted treatments, and incomplete documentation. These actions and inactions directly led to the deficiencies cited by surveyors.
Failure to Change Oxygen and Nebulizer Tubing per Physician Orders
Penalty
Summary
Facility staff failed to provide respiratory care services in accordance with professional standards and physician orders for two residents who required oxygen and nebulizer therapy. Specifically, staff did not change the oxygen and nebulizer tubing weekly as ordered by the physicians and outlined in the facility's policy. Observations revealed that the tubing for both oxygen and nebulizer equipment was dated well beyond the required weekly change interval for both residents. One resident, with a history of cerebral infarction, chronic heart failure, and atrial fibrillation, was dependent on staff for daily care and used continuous oxygen therapy and daily nebulizer treatments. Despite physician orders and care plan interventions specifying weekly changes and dating of tubing, the oxygen and nebulizer tubing in use was observed to be dated nearly two weeks prior, indicating it had not been changed as required. Interviews with nursing staff and the DON confirmed that the expectation was for weekly changes, and that staff administering treatments should have noticed the outdated tubing. A second resident, diagnosed with acute and chronic respiratory failure and COPD, also required oxygen therapy. Observations showed that this resident's oxygen tubing was similarly dated beyond the weekly interval specified in the physician's orders and care plan. Staff interviews confirmed that the tubing should have been changed weekly and that the observed dates did not meet this requirement.
Unattended and Unlocked Treatment Carts with Medications
Penalty
Summary
Nursing staff failed to store drugs and biologicals in accordance with State and Federal requirements, as evidenced by multiple observations of unlocked and unattended treatment carts in two separate halls. On several occasions, the treatment carts were left unsupervised and accessible to staff and residents, with the surveyor able to access prescription ointments, creams, and other treatment supplies inside the carts. These observations occurred over two consecutive days and involved multiple staff and residents passing by the unsecured carts. Facility policy requires that medication carts and supplies be locked when not attended by authorized personnel. During interviews, both a nurse and facility leadership confirmed that treatment carts should remain locked unless a nurse is present. Despite this policy, the carts were repeatedly left unlocked and unsupervised, directly violating facility procedures and regulatory requirements for medication security.
Failure to Implement Hand Hygiene and Glove Use Protocols by Housekeeping Staff
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as required by its own policies. Specifically, two housekeeping staff members did not perform hand hygiene after removing gloves and before donning new gloves, as observed multiple times during their cleaning routines. One housekeeper was seen exiting a resident's room wearing gloves, touching the housekeeping cart and various cleaning supplies, and then entering another resident's room without changing gloves or performing hand hygiene. This sequence was repeated, with the staff member continuing to use the same potentially contaminated gloves across different rooms and tasks. Another housekeeper also failed to perform hand hygiene between glove changes and was observed wearing gloves in the hallway, which is against facility policy. Interviews with the housekeeping staff, the unit manager, and the infection control preventionist nurse confirmed that staff are expected to perform hand hygiene before and after glove use, not wear gloves in the hallway, and change gloves between rooms and tasks. Despite this, the observed actions of the housekeeping staff did not align with these expectations, resulting in a failure to follow established infection control procedures designed to prevent the spread of infection among residents, staff, and visitors.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure proper notification and documentation following an unwitnessed fall involving a resident. On the specified date, a nurse found the resident lying on the floor in an unoccupied room. Despite assessing the resident and finding no immediate visible injuries, the nurse did not report the incident to the physician, the resident's guardian, the Director of Nurses (DON), or the oncoming shift nurse, as required by the facility's policy. Additionally, there was no documentation of the fall in the resident's medical record, including a progress note or a Fall/Incident Report. The resident, who had a history of falls and multiple medical conditions including dementia and diabetes, was later found to have elevated blood sugar levels and was transferred to the hospital. It was at the hospital that the resident was discovered to have rib fractures, bruising, and sepsis. The facility's report indicated that the nurse failed to notify the necessary parties and did not complete the required documentation or assessments following the fall. Interviews with the nursing staff and the DON revealed that the nurse did not follow the facility's protocol for reporting and documenting the incident. The DON and the facility administrator were not informed of the fall until after the resident was transferred to the hospital and the hospital staff notified the facility of the resident's injuries. The lack of communication and documentation was a clear violation of the facility's policies and procedures for handling such incidents.
Failure to Document and Assess After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received nursing care and treatment that met professional standards of quality care following an unwitnessed fall. On the specified date, a nurse found the resident lying on the floor in an unoccupied room. Although the nurse claimed to have assessed the resident for potential injuries, there was no documentation in the medical record to support that any assessment, including vital signs, was completed immediately after the fall. The resident, who had a history of dementia, type II diabetes, hypertension, osteoarthritis, schizophrenia, delusional disorders, anxiety, depression, and previous falls, was later transferred to the hospital due to high blood glucose levels and mental status changes. The hospital reported that the resident had rib fractures, bruising, and sepsis. Despite the nurse's assertion that an assessment was conducted, the lack of documentation and failure to follow the facility's policy on resident assessment and incident reporting were noted. Interviews with the nursing staff revealed that the incident was not properly communicated to the facility's administration until after the resident's condition worsened. The Director of Nurses confirmed the absence of documentation regarding the fall and the expected procedures that should have been followed, including obtaining neurological signs and completing a fall packet, were not adhered to.
Failure to Implement Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to ensure that resident-centered care plans were implemented for one resident out of a total sample of 14 residents. Specifically, for Resident #43, the facility did not implement the use of TED hose (compression stockings) as ordered by the physician. Resident #43, who has severe cognitive impairment and multiple diagnoses including cerebral infarction, aortic aneurysm, and hypertension, was observed on multiple occasions without the prescribed compression stockings. The care plan and physician's order clearly indicated the need for TED hose to be worn every morning and removed every bedtime to minimize syncopal episodes, but this was not followed. Interviews with the nursing staff revealed a lack of awareness regarding the resident's need for compression stockings. Both the nurse and the CNA assigned to Resident #43 were unaware of the physician's order for TED hose. The Director of Nursing confirmed that the staff should follow each resident's plan of care and expressed that the compression stockings should have been applied as per the physician's order. The failure to implement the care plan as ordered resulted in a deficiency in resident-centered care for Resident #43.
Failure to Develop Individualized Trauma Informed Care Plans
Penalty
Summary
The facility failed to ensure a plan of care was developed for Trauma Informed Care with individualized interventions for two residents with a history of Post Traumatic Stress Disorder (PTSD). Resident #3, who was admitted in January 2018, had diagnoses including anxiety disorder, major depressive disorder, and dementia. The resident's care plan did not identify specific triggers for retraumatization, despite the resident's history of physical and sexual abuse. The care plan was generic and did not include the resident's preference for female caregivers, which was only updated after the surveyor's interview with the social worker and the Director of Nursing (DON). The resident exhibited behaviors such as yelling out, resistance to care, and selective medication intake, which were not adequately addressed in the care plan. The social worker admitted to not discussing the PTSD with the family, despite their involvement, and acknowledged that the care plan should have been individualized with specific triggers and preferences noted upon admission and during quarterly assessments. Resident #41, admitted in April 2024, also had a history of PTSD, anxiety, and depression. The resident's PTSD and Trauma Assessment did not indicate specific triggers for retraumatization, and the care plan was similarly generic. The resident's son provided information about the history of trauma, but the assessment failed to document potential triggers or the need for female-only caregivers, despite the resident's history of sexual assault. The social worker confirmed that the care plan should have included specific triggers and interventions, and acknowledged that the care plan was updated only after the surveyor's interview. Both residents' care plans lacked individualized interventions and failed to identify specific triggers for retraumatization, which is a critical component of trauma-informed care. The facility's policy on Trauma Informed Care was not adequately followed, leading to deficiencies in the care provided to residents with PTSD. The Director of Nursing (DON) confirmed that it was the expectation for care plans to be individualized for residents with PTSD, but this was not done in these cases.
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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