Beaumont Rehab & Skilled Nursing Ctr - Northboro
Inspection history, citations, penalties and survey trends for this long-term care facility in Northborough, Massachusetts.
- Location
- 238 West Main Street, Northborough, Massachusetts 01532
- CMS Provider Number
- 225513
- Inspections on file
- 19
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Beaumont Rehab & Skilled Nursing Ctr - Northboro during CMS and state inspections, most recent first.
Dietary staff failed to change gloves and perform hand hygiene when moving between tasks and areas in the kitchen, including after handling dirty trays and utensils, resulting in improper food handling during meal service. The Food Service Director confirmed that required protocols for glove use and handwashing were not followed.
Staff did not consistently use required PPE, such as gowns and gloves, during high-contact care activities for residents on Enhanced Barrier Precautions, including changing linens and providing denture care. A resident with wounds and another with a PICC line received care without staff adhering to the facility's EBP policy, as staff either omitted gowns or failed to change gloves and perform hand hygiene as required.
A resident with dementia and high risk for pressure ulcers was found repeatedly lying on a deflated air mattress that was not functioning due to being plugged into a non-working outlet. Despite physician orders and documentation indicating the mattress was checked every shift, surveyor observations and staff interviews confirmed the mattress was not operational and required monitoring was not performed.
A resident with severe cognitive impairment was handled roughly by a CNA, as witnessed by an Activity Aide, who failed to report the incident immediately. The incident was only reported the following day by a family member, leading to an investigation and the CNA's suspension and termination.
The facility failed to have an RN on duty for at least eight consecutive hours on four days, as required. This was confirmed through a review of the PBJ Report and interviews with the facility Administrator, Facility Scheduler, and DON. The absence of an RN placed all residents at risk for unmet clinical needs.
The facility failed to ensure that Advance Directives were accurate for two residents. One resident's MOLST form was signed by someone other than the resident or the appointed HCP before the HCP was invoked. Another resident's MOLST form was signed by someone other than the resident or the appointed HCP, despite the resident being cognitively intact at the time.
The facility failed to ensure privacy and confidentiality for a cognitively impaired resident who was observed naked and attempting to dress in their bedroom. Staff members did not take appropriate actions to cover the resident or draw the privacy curtain, leaving the resident exposed to anyone looking into the room.
The facility failed to provide necessary dining assistance to two residents with dementia, leading to difficulties in accessing and consuming their meals. Staff did not intervene in a timely manner, leaving the residents struggling to eat.
A resident with a history of malignant neoplasm of the hard palate and requiring a pureed diet was able to consume regular textured food from another resident's meal tray due to inadequate supervision during meal time. Staff were either assisting other residents or not in the immediate vicinity, leading to the resident eating food that could potentially cause health issues.
The facility failed to monitor gastric residuals for a resident with a G-tube, as required by their policy. The resident, admitted with cerebral infarction and dysphagia, did not have Physician's orders to check residuals until several days after admission. The Unit Manager confirmed that the policy was not followed.
The facility failed to provide appropriate pain management for a resident with terminal cancer and mild cognitive impairment. Despite physician orders for pain assessments every shift, the facility did not consistently assess or document the resident's pain levels, leading to unmanaged pain and incomplete administration of prescribed pain medication.
The facility failed to perform trauma assessments at the time of admission for two residents with Dementia and Depression, leading to a deficiency in trauma-informed care. The Social Worker confirmed that trauma assessments were not completed if no history of trauma was identified, contrary to the facility's policy.
The facility failed to securely store and administer medications for a resident with moderate cognitive impairment. Medications were left unattended at the resident's bedside, contrary to facility policy and without proper assessment for self-administration.
Failure to Follow Sanitation and Food Handling Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices in the main kitchen, as observed during a breakfast meal service. Dietary staff were seen handling food items and food trays, then moving around the kitchen and touching various surfaces without changing gloves or performing appropriate hand hygiene. Specifically, one staff member handled both clean and dirty trays and continued to serve food without changing gloves or washing hands, despite stepping away from the serving line and handling potentially contaminated items. Another staff member also failed to change gloves or wash hands after leaving the serving line to retrieve a utensil and then returning to serve food. Facility policies required that gloves be changed and hands washed after handling soiled items, after removing gloves, and when moving between different tasks or areas, but these procedures were not followed. The Food Service Director confirmed during interviews that the staff did not comply with the required hand hygiene and glove use protocols as outlined in the facility's policies. No information about specific residents or their medical conditions was provided in the report.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP), as observed during multiple care activities. One resident, admitted with an open abdominal wound and atherosclerosis with ulceration, had physician orders for EBP, including the use of gowns and gloves during high-contact care such as changing linens. A CNA was observed removing soiled linens and handling clean linens for this resident while wearing gloves but not a gown, and failed to remove gloves or perform hand hygiene before exiting the room to obtain clean linens. The CNA acknowledged awareness of the EBP order but did not follow the required protocol, and later admitted she should have worn a gown and changed gloves as indicated by the signage and orders. Further observations revealed another CNA entering a room with EBP signage to perform denture care for a resident with a PICC line. The CNA donned gloves but not a gown, handled the resident's dentures, and performed hand hygiene only after completing the task. The CNA stated she was unaware of the specific reason for the precautions and did not believe a gown was necessary for denture care. Facility leadership, including the unit manager and CNO, confirmed that gowns and gloves were required for these high-contact activities under the facility's EBP policy. The facility's policy on EBP, dated 4/6/23, specifies that gowns and gloves must be used during high-contact care activities for residents with wounds or indwelling devices, regardless of MDRO status. Examples of such activities include dressing, bathing, transferring, providing hygiene, changing linens, and wound care. The observed failures to use appropriate PPE and perform hand hygiene as required by policy and physician orders resulted in a deficiency related to infection control practices.
Failure to Maintain Functioning Air Mattress for Pressure Relief
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, total dependence for activities of daily living, and at risk for pressure ulcers was not provided with a functioning air mattress as ordered by the physician. The air mattress, intended to provide pressure relief, was observed on multiple occasions to be deflated and not operating because it was plugged into a non-functioning electrical outlet. Despite physician orders and care plan interventions specifying the use of an air mattress and regular monitoring for comfort every shift, the mattress remained non-operational over at least two days of surveyor observation. Documentation indicated that staff were recording daily checks of the air mattress for comfort on the Medication Administration Record, but direct observation by the surveyor revealed the mattress was not inflated and the power was off during these checks. Interviews with nursing staff and the DON confirmed that the mattress was not functioning and that required checks had not been properly performed, resulting in the resident not receiving the prescribed pressure-relieving therapy.
Failure to Report Abuse Incident Immediately
Penalty
Summary
The facility failed to ensure that staff implemented and followed their abuse policy when an Activity Aide witnessed a staff member handle a resident in a potentially abusive manner but did not report the incident immediately. The incident occurred on 7/22/24 when the Activity Aide saw a CNA push down on the resident's shoulders in a rough manner as the resident attempted to stand in the activity room. The resident involved had severe cognitive impairment, requiring substantial assistance for transfers and ambulation, and had a care plan indicating the need for staff to anticipate and meet his or her needs. The incident was not reported until the following day, 7/23/24, when a family member who witnessed the event reported it to the facility. The Director of Nurses confirmed that the Activity Aide should have reported the incident immediately to administration. An investigation was initiated on 7/23/24, and the CNA involved was suspended and later terminated. The facility's policy required immediate reporting of any witnessed or known abuse, which was not adhered to in this case.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have an RN working for eight consecutive hours on four days between 10/1/23 and 12/31/23. This deficiency was identified through a review of the Fiscal Year Quarter One Payroll Based Journal (PBJ) Report, which indicated no RN was present for the required hours on 10/1/23, 10/29/23, 11/12/23, and 12/3/23. Interviews with the facility Administrator, Facility Scheduler, and Director of Nurses (DON) confirmed the absence of an RN on these dates. The facility had no nurse staffing waivers in place during this period, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing.
Failure to Ensure Valid Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for two residents. For one resident, the MOLST form was signed by someone other than the resident or the appointed Health Care Proxy (HCP) before the HCP was invoked. The Director of Nurses (DON) confirmed that the MOLST form was not valid and should have been updated upon the resident's admission to the facility. The resident had been admitted with vascular dementia and was cognitively impaired, as indicated by the Minimum Data Set (MDS) assessment. For another resident, the MOLST form was also signed by someone other than the resident or the appointed HCP. The resident was cognitively intact at the time of admission, as evidenced by a BIMS assessment score of 14 out of 15. The DON acknowledged that the MOLST form was invalid because it had been signed by verbal authorization of a person who was not the resident's HCP. The resident had been admitted with a diagnosis of malignant neoplasm, and the HCP had been invoked after the MOLST form was signed.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to provide privacy and confidentiality for Resident #27, who was observed naked and attempting to dress in their bedroom. Despite being cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS) exam, the resident was left exposed. On 5/7/24, the surveyor observed the resident naked in their wheelchair from the bedroom doorway. Nurse #1, who was nearby, did not assist the resident or ensure their privacy by drawing the curtain or closing the door. Similarly, CNA #2 entered the room to obtain an item for the resident's roommate but did not cover the resident or draw the privacy curtain, leaving the resident exposed to anyone looking into the room. Interviews with the staff confirmed the oversight. Nurse #1 acknowledged that the resident should have been covered or the privacy curtain drawn. CNA #1 stated that she would have covered the resident with a sheet if she had seen them naked from the hallway. The Unit Manager also confirmed that the staff should have covered the resident when exposed. CNA #2 admitted to seeing the resident naked and informed the CNA on the resident's assignment but did not take any action to cover the resident or ensure their privacy.
Failure to Provide Dining Assistance
Penalty
Summary
The facility failed to provide necessary assistance during dining service for two residents, leading to a risk of reduced nutritional intake. Resident #54, who was diagnosed with dementia and required setup/clean-up assistance for eating, was observed struggling to open food containers and access meal items. Despite the resident's visible difficulty, staff did not intervene in a timely manner, leaving the resident unable to consume his/her meal properly. The resident was seen attempting to open a milk carton and eat with fingers, but no staff were present to assist until much later, resulting in the resident pushing away from the table without having eaten adequately. Similarly, Resident #61, who had dementia and Parkinson's disease and required setup assistance for eating, was observed struggling to eat his/her breakfast. The resident attempted to pick up pancakes with a spoon and brought an empty spoon to his/her mouth multiple times. The resident also scooped across the tablecloth and held multiple utensils without successfully eating. Staff did not provide the necessary assistance until much later, leaving the resident without proper access to his/her meal. Interviews with staff revealed that they were aware of the residents' needs for assistance but failed to provide timely help. The MDS Nurse and Unit Manager acknowledged that staff should have offered to open food items and assist residents who showed difficulty in accessing their meals. The lack of timely intervention and assistance during meal times for these residents highlights a deficiency in the facility's dining service and care practices.
Inadequate Supervision During Meal Time
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident during meal time, leading to the resident consuming food that was not consistent with their prescribed diet. The resident, who had a history of malignant neoplasm of the hard palate and required a pureed diet due to swallowing difficulties, was able to obtain and eat regular textured food from another resident's meal tray. This incident occurred despite the facility's policy to adhere to therapeutic diets and provide proper assistance to residents as needed. The resident was observed in the dining room seated next to another resident. After the other resident left the table, staff returned the meal tray, which included a partially eaten breakfast sandwich and a muffin. The resident, who had finished their own pureed meal, was left unsupervised and subsequently took a bite of the muffin from the other resident's tray. The staff present in the dining area were either assisting other residents or not in the immediate vicinity, leading to a lack of supervision for the resident. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dietary needs. The Dementia Special Care Unit Program Director acknowledged the resident's tendency to wander and pick up items belonging to others but could not speak to the level of supervision provided during meals. The Unit Manager incorrectly believed the resident was on a regular diet, and the Speech Language Pathologist confirmed that the resident should remain on a pureed diet due to the risk of complications from consuming regular textured food. The failure to provide adequate supervision and adhere to the resident's dietary requirements resulted in the resident consuming food that could potentially cause health issues.
Failure to Monitor Gastric Residuals for G-Tube
Penalty
Summary
The facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube) for a resident. The staff did not obtain Physician's orders to check for gastric residual volume, which is necessary to identify and prevent complications associated with enteral feeding. The facility's policy required checking residuals once per shift or per Physician order to minimize potential complications such as vomiting, distention, and aspiration. However, this was not done for the resident from the time of admission until the first day of the Department of Public Health (DPH) survey. The resident was admitted with diagnoses including cerebral infarction and dysphagia, necessitating the use of a G-tube. The care plan indicated that enteral feeding management should be per Physician's orders. Despite this, the Medication Administration Record (MAR) did not show any orders or checks for gastric residuals until several days after admission. During an interview, the Unit Manager acknowledged that the Physician's order to check for gastric residuals should have been in place upon admission, as per facility policy, but it was not followed.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #28, who was admitted with diagnoses including malignant neoplasm of the reproductive system and mild cognitive impairment. Despite physician orders requiring pain assessments every shift using a numeric pain scale, the facility did not consistently assess or document the resident's pain levels. Interviews with the resident and nursing staff revealed that the resident experienced significant pain and did not always receive the prescribed pain medication. The resident reported instances where only half of the prescribed pain medication was administered, leading to unmanaged pain levels that affected daily activities. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from December 2023 to May 2024 showed no evidence of documented pain assessments using the numeric pain scale. Nursing staff confirmed that the pain assessments were not documented as required, and the Unit Manager acknowledged that the physician's order had been entered incorrectly into the computer system. This lack of proper documentation and assessment resulted in the facility's failure to manage the resident's pain effectively, as per professional standards and the facility's own pain management policy.
Failure to Perform Trauma Assessments at Admission
Penalty
Summary
The facility failed to perform trauma assessments at the time of admission for two residents, leading to a deficiency in trauma-informed care. Resident #45, admitted in June 2023 with diagnoses of Dementia and Depression, had no evidence in their clinical record of being assessed for a history of trauma. The Social Worker (SW) confirmed during an interview that a trauma assessment would not have been completed if no history of trauma was identified, indicating a lapse in the facility's policy implementation. Similarly, Resident #79, admitted in May 2023 with diagnoses of Dementia and Major Depressive Disorder, also had no evidence of a trauma assessment in their clinical record. The SW acknowledged responsibility for screening all residents for trauma history upon admission but admitted that there was no evidence that Resident #45 and Resident #79 had been screened for trauma since their admission. This failure to conduct trauma assessments is contrary to the facility's policy, which mandates that all residents be assessed for trauma history upon admission.
Failure to Securely Store and Administer Medications
Penalty
Summary
The facility failed to ensure that medications were stored and administered in a secure and safe manner for one resident. Specifically, medications were left unattended in a medication cup at the bedside of a resident who was moderately cognitively impaired. The resident had diagnoses including arthrosclerosis of arteries in both legs, atrial fibrillation, mild cognitive impairment, and dysphagia. The facility's policy required medications to be stored safely and securely, and for medications to be administered in a safe and effective manner. The resident had not been assessed as a candidate for self-administration of medications. On the day of the survey, a surveyor observed a small plastic cup containing multiple pills on the bedside table next to the resident. The resident stated that staff usually leave medications on the bedside table for him/her to take independently. A nurse confirmed that she left the medications at the bedside because the resident likes to take them independently, but acknowledged that she should have watched the resident take the medications and should not have left them unattended. The unit manager confirmed that the resident had not been assessed to safely administer his/her own medications and that the nurse should not have left medications at the bedside unattended.
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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