Belmont Manor Nursing Home, In
Inspection history, citations, penalties and survey trends for this long-term care facility in Belmont, Massachusetts.
- Location
- 34 Agassiz Avenue, Belmont, Massachusetts 02478
- CMS Provider Number
- 225419
- Inspections on file
- 17
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Belmont Manor Nursing Home, In during CMS and state inspections, most recent first.
A resident with Alzheimer’s, dementia, a history of falls, and severe cognitive impairment had an MD order and care plan for a wander guard device on a walker, with nightly function checks required on the 11 P.M.–7 A.M. shift using a universal tester. On the day of the incident, the TAR showed no documentation that the required wander guard check was completed, and the assigned nurse later stated she did not test the device because she did not want to wake the resident, despite facility policy requiring such checks. The device was not functioning, allowing the resident to leave the unit, use the elevator, and exit to an outdoor courtyard without triggering the wander guard alarm system, where the resident was later found outside with the walker nearby.
The facility failed to maintain the dignity of a resident by not placing their urinary catheter bag in a privacy bag, leading to embarrassment. Another resident with impaired cognition was not provided a dignified dining experience, as they were left waiting for assistance with food out of reach. On two units, staff were observed standing over residents while feeding them, rather than sitting at eye level. Additionally, a CNA was seen using a cell phone while assisting a resident with their meal.
The facility did not develop baseline care plans within 48 hours for four residents with severe cognitive impairments, including dementia. Despite policy requirements, medical records lacked these plans, and comprehensive care plans did not reflect necessary interventions. Interviews with Nurse Unit Managers confirmed the oversight.
The facility failed to develop individualized dementia care plans for residents in the Dementia Special Care Unit (DSCU), affecting their ability to receive appropriate treatment and services. Despite severe cognitive impairments, residents lacked person-centered care plans, and staff interviews revealed unclear responsibilities for care plan development. This deficiency highlights a systemic issue in the facility's approach to dementia care planning.
The facility failed to accurately document care for several residents, including the use of padded side rails, oxygen tubing changes, and the application of a palmar guard. Observations revealed discrepancies between documented care and actual practices, affecting residents with conditions such as Alzheimer's, epilepsy, COPD, and hemiplegia.
A resident, assessed as unable to self-administer medications, was found with pills left at the bedside for self-administration. Despite facility policy requiring an interdisciplinary assessment to determine self-administration capability, the resident was left with medications unattended. Nursing staff interviews confirmed the oversight, and the DON acknowledged the resident should not have had access to self-administer medications.
A resident with Alzheimer's dementia and other conditions was found with bruises on both hands, which were not documented or investigated by the facility. Despite facility policy requiring investigation of unknown bruises, staff failed to report or investigate the bruises, and the Director of Nursing and Staff Development Coordinator were unaware of the full extent of the issue.
A facility failed to report bruises of unknown origin on a resident to the state agency within the required timeframe. The resident, with Alzheimer's dementia and other conditions, was observed with bruises on both hands, which were not documented in medical records. A nurse noticed the bruises but did not inform the charge nurse, and a CNA saw the bruises before an incident but did not report them immediately. The Staff Development Coordinator was only aware of one bruise and did not report it, assuming it was witnessed.
A facility failed to create individualized care plans for a resident's ADLs and psychotropic medication use. The resident, with severe cognitive impairment and dependence on ADLs, was taking antipsychotic medication. Despite these needs, the medical record lacked specific interventions, and staff interviews confirmed the absence of necessary care plans.
A facility failed to update a care plan for a resident's healed stage 3 pressure ulcer on the left heel. Despite the ulcer being healed, the care plan still listed it as an active problem. The resident, with diagnoses including type 2 diabetes and hemiplegia, was observed on an air mattress with a blanket cradle. Interviews with staff confirmed the ulcer had healed long ago, and the care plan should have been resolved during the quarterly MDS review.
A resident with hemiplegia and hemiparesis was not provided with a prescribed palmar guard for contracture management, as observed during multiple instances. Despite a physician's order, the device was not applied, and there was no documentation of refusal. Staff interviews revealed a lack of awareness and adherence to the intervention, with the Director of Rehabilitation unaware of the non-compliance. The Nurse Unit Manager emphasized the importance of accurate documentation and referrals to rehab if the resident did not use the recommended device.
The facility failed to implement physician-ordered padded side rails for two residents with severe cognitive impairments and specific medical conditions. One resident with Alzheimer's dementia was repeatedly observed without padded side rails, contrary to orders. Another resident with epilepsy and a history of falls had only one side rail padded instead of both, as required. Staff interviews confirmed the expectation to follow these orders, which was not met.
A resident experienced significant weight loss due to the facility's failure to implement timely interventions and communicate effectively with the dietitian. Despite having a healthy appetite, the resident lost 15% of their body weight over six months. The dietitian was not informed of the weight loss until a routine assessment, and the facility's policy for monitoring and addressing weight changes was not followed.
The facility failed to maintain clean oxygen concentrator filters and change oxygen tubing as ordered for two residents with chronic obstructive pulmonary disease. Observations revealed thick layers of dust on filters, and one resident's tubing was not changed weekly as prescribed. Staff were unaware of cleaning responsibilities, and there was no documentation or system to track maintenance. Additionally, a resident was not assessed for the ability to change their own tubing, contrary to facility policy.
A nurse failed to disinfect a portable vital sign caddy between uses on two residents under enhanced barrier precautions (EBP), contrary to the facility's infection control policy. The nurse admitted the oversight, and the nurse unit manager confirmed the requirement for disinfection between uses.
Failure to Test Wander Guard Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident at risk for elopement, with an MD order for a wander guard device, had that device consistently checked for proper function. The resident had diagnoses including Alzheimer’s, dementia, diabetes, history of falling, and difficulty in walking, and was assessed as cognitively impaired with a BIMS score of 7, indicating severe cognitive impairment. The resident’s care plan and elopement risk assessment identified a history of wandering and risk for elopement, and the resident’s wander guard was ordered to be placed on the walker, with a requirement that nursing staff check its function daily on the 11:00 P.M. to 7:00 A.M. shift using a universal tester. On the date of the incident, documentation on the Treatment Administration Record for the 11:00 P.M. to 7:00 A.M. shift showed no evidence that the required wander guard function check had been completed. Nurse #1 later stated that she did not perform the wander guard function test during her shift because she did not want to wake the resident, although she observed that the device was attached to the walker. Facility policy and staff development information indicated that universal testers were available on each unit and that wander guard checks were to be conducted on the night shift, but this process was not followed for this resident on the day in question. As a result of the wander guard device not being tested and not functioning, the resident was able to leave the unit undetected. According to staff interviews and the facility’s report, the resident was last seen in the room watching television at approximately 6:30 A.M. and was discovered missing around 7:00 A.M. A search was initiated, and the resident was found on the first floor outside in the courtyard, sitting on the ground with the walker nearby. Staff confirmed that the wander guard device did not trigger an alarm when the resident left the unit, accessed the elevator, and exited to the courtyard, and it also did not alarm when the resident was brought back inside, demonstrating that the system was not functioning at the time of the elopement.
Dignity and Dining Experience Deficiencies
Penalty
Summary
The facility failed to maintain the dignity of Resident #222 by not placing their urinary catheter bag in a privacy bag, as required by the facility's policy on indwelling Foley catheter care. Resident #222, who has intact cognition, expressed embarrassment over the exposed catheter bag, which was visible from the hallway during observations on two separate occasions. Charge Nurse #1 confirmed that it is the responsibility of the Certified Nurse's Aides and nurses to ensure catheter bags are placed inside privacy bags. Resident #23, who has severely impaired cognition and requires assistance with eating, was not provided a dignified dining experience. On multiple occasions, Resident #23 was observed with food placed out of reach and was left waiting for assistance while watching others eat. Staff members were observed standing over Resident #23 while feeding, rather than sitting at eye level and interacting with the resident, as recommended by the Nurse Unit Manager and the Director of Nursing. On the Station 2 unit, similar issues were observed where residents dependent on staff for eating were left waiting with food in front of them. Staff members were seen standing over residents while feeding them, rather than sitting at eye level. Additionally, on the Station 4 unit, a CNA was observed using a cell phone while assisting a resident with their meal, which was acknowledged as inappropriate by Nurse Unit Manager #3.
Failure to Develop Baseline Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents diagnosed with dementia, among other conditions. These residents were admitted or readmitted to the facility with severe cognitive impairments, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours to address immediate health and safety needs, the medical records for these residents did not indicate that such plans were created. This lack of baseline care plans meant that individualized interventions related to the residents' dementia and its progression were not documented. Interviews with Nurse Unit Managers confirmed that the nursing staff should have developed baseline care plans for these residents within the required timeframe. The absence of these plans was noted for residents with various diagnoses, including dementia, Parkinson's disease, bipolar disorder, depression, anxiety, metabolic encephalopathy, and acute kidney injury. The comprehensive care plans also failed to reflect the residents' dementia diagnoses and necessary interventions, highlighting a significant oversight in meeting professional standards of quality care for these individuals.
Failure to Develop Dementia Care Plans in DSCU
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate treatment and services through the development and implementation of individualized care plans. This deficiency was identified for five residents who were diagnosed with dementia and resided in the facility's Dementia Special Care Unit (DSCU). Despite the facility's disclosure of meeting state licensure requirements for specialized dementia care, the interdisciplinary team did not develop dementia-specific care plans for these residents. Resident #21, admitted with severe unspecified dementia and agitation, was found to have no person-centered care plan addressing their cognitive impairment and behaviors. Interviews with facility staff revealed that the responsibility for developing such a care plan was not clearly assigned, resulting in the absence of a tailored approach to managing the resident's dementia-related needs. Similarly, Residents #103, #41, and #25, all residing in the DSCU with severe cognitive impairments, also lacked interdisciplinary dementia care plans, as confirmed by the Nurse Unit Manager. Resident #69, who was readmitted with dementia and other medical conditions, did not have a baseline care plan for dementia upon readmission, nor were individualized interventions developed. The Nurse Unit Manager acknowledged the necessity for a specific care plan for residents with dementia, especially following readmission after hospitalization. The absence of these care plans indicates a systemic issue in the facility's approach to dementia care planning, affecting the residents' ability to attain or maintain their highest practicable well-being.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the use of padded side rails for two residents, despite physician orders requiring them. Resident #77, diagnosed with Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, contrary to the documentation in the Treatment Administration Record (TAR) which indicated they were in place. Similarly, Resident #57, with epilepsy and a history of falls, was observed with only one side rail padded, while the TAR inaccurately documented that both side rails were padded. For Resident #53, who has chronic obstructive pulmonary disease (COPD) and is cognitively intact, the facility failed to change the oxygen tubing as per the physician's order. The tubing was observed to be unchanged for five weeks, despite the Medication Administration Record (MAR) indicating it had been changed weekly. This discrepancy highlights a failure in accurately documenting the care provided to the resident. Resident #32, with hemiplegia and moderately impaired cognition, was supposed to have a palmar guard applied to manage contractures. However, observations revealed that the palmar guard was not applied, and there was no documentation of refusal by the resident. The TAR inaccurately indicated that the palmar guard was applied, despite the absence of the device during multiple observations.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications, despite being assessed as unable to do so. The resident, who was admitted with diagnoses including adult failure to thrive and hypertension, was observed with pills left at the bedside for self-administration. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, and this assessment indicated that the resident was not a candidate for self-administration due to cognitive, physical, or visual limitations. On a specific date, a surveyor observed two brown pills in a medication cup on the resident's bedside table while the resident was out for an appointment. Interviews with nursing staff revealed that the pills were left by a nurse for the resident to take later, which was against the facility's policy. The Charge Nurse confirmed that the resident should not have been left with medications unattended, as the assessment had not changed since admission. The Director of Nursing reiterated that the resident was not permitted to self-administer medications, and the pills should not have been left at the bedside.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate bruises of unknown etiology for a resident, identified as Resident #4, who was admitted with diagnoses including Alzheimer's dementia, kidney disease, and diabetes. The resident was observed with dark purple bruises on both hands, which were not documented in the medical record or noted during weekly skin checks. The facility's policy required obtaining caregiver statements for bruises of unknown origin, but this was not followed. Nurse #2 noticed the bruises but did not report them to the charge nurse, and Charge Nurse #1 was unaware of the bruises and did not initiate an investigation or report to the state agency as required. CNA #1 observed the bruises before providing care and before the resident hit their hand on the bedrail, but failed to report them immediately. The Director of Nursing and the Staff Development Coordinator were not aware of the bruises on both hands, and the incident was not thoroughly investigated or reported. The facility's documentation was incomplete, failing to question other staff members or provide a comprehensive account of the bruises' origin.
Failure to Report Bruises of Unknown Origin
Penalty
Summary
The facility failed to report bruises of unknown origin on a resident to the state agency within the required two-hour timeframe. The resident, who was admitted in December 2016, has Alzheimer's dementia, kidney disease, and diabetes, and is severely cognitively impaired, requiring maximum assistance with activities of daily living. On a specific date, a surveyor observed dark purple bruises on both of the resident's hands, which were not documented in the medical record or noted in the weekly skin checks or progress notes for November and December. Nurse #2 noticed the bruises but did not inform the charge nurse, and Charge Nurse #1 was unaware of the bruises until the surveyor's observation. An incident report dated in November indicated a bruise on the resident's left hand, but not the right, and noted the resident was combative and hit their hand on the bedrail. CNA #1 reported seeing the bruises before providing care and before the resident hit the bedrail, but did not immediately report it to the manager. The Staff Development Coordinator was only aware of the left hand bruise and did not report it to administration, assuming it was witnessed. The Director of Nursing confirmed that all injuries of unknown origin should be reported to the state agency within the required timeframe.
Failure to Develop Individualized Care Plans for ADLs and Psychotropic Medication
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for a resident, specifically in relation to activities of daily living (ADLs) and the use of psychotropic medication. The resident, who was admitted in January 2024, had diagnoses including dementia with psychotic disturbance, Parkinson's disease, and difficulty walking. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment, dependence on ADLs, and the use of antipsychotic medication. However, the medical record did not include individualized interventions for the resident's ADL needs or psychotropic medication monitoring. Interviews with facility staff revealed that the MDS nurse did not develop a care plan for the resident's ADL and psychotropic medication needs, and the Care Area Assessment (CAA) referred to nursing for care plan development. The Nurse Unit Manager acknowledged that a care plan should have been developed based on the resident's diagnoses, medications, and other care needs, but it was not present in the resident's care plans.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after the quarterly review assessment. Specifically, the care plan for a stage 3 pressure ulcer on the resident's left heel was not updated or resolved, despite the ulcer having healed a long time ago. The resident, who was admitted in October 2020, has diagnoses including type 2 diabetes mellitus and hemiplegia and hemiparesis following a cerebral infarction. The most recent Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and did not have any unhealed pressure ulcers, yet the care plan still included an outdated problem related to the pressure ulcer. Observations and interviews revealed that the resident was resting on an air mattress with a blanket cradle, and did not respond when asked about any wounds. Nurse #5 confirmed that the pressure ulcer had healed a long time ago, and Nurse Unit Manager #3 acknowledged that the care plan should have been resolved during the care plan review after the quarterly MDS assessment. The failure to update the care plan reflects a lapse in the facility's process for reviewing and revising care plans in accordance with the MDS schedule.
Failure to Implement Contracture Management Intervention
Penalty
Summary
The facility failed to implement an intervention for contracture management in accordance with the medical plan of care for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who had moderately impaired cognition and functional limitation in the range of motion of the upper extremity, was observed multiple times without the prescribed palmar guard on the right hand. The medical record indicated a physician's order for the palmar guard to be worn during specific hours, but observations revealed that the device was not applied, and there was no documentation of refusal by the resident. Interviews with staff revealed a lack of awareness and adherence to the prescribed intervention. A CNA was unaware of any device for the resident's right hand, and a nurse mentioned that the resident might not wear the palmar guard due to behaviors, but this was not documented as a refusal. The Director of Rehabilitation confirmed the importance of the palmar guard in preventing skin issues and worsening contractures, and stated that she was not informed of the resident's non-compliance. The Nurse Unit Manager acknowledged that the palmar guard was necessary to prevent worsening contractures and emphasized that the intervention should be documented accurately, with referrals to rehab if the resident did not use the recommended device.
Failure to Implement Physician-Ordered Padded Side Rails
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent accidents for two residents. Resident #77, who has Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, despite a physician's order for them due to agitation. The observations occurred over several days, and interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the order to be followed, yet the padded side rails were not in place. Similarly, Resident #57, who has epilepsy, dementia, and a history of falling, was observed with only one side rail padded instead of both, as per the physician's order. This resident was also assessed to have severely impaired cognition and required total care. The observations were consistent over several days, and interviews with nursing staff and the Director of Nursing reiterated that both side rails should have been padded to prevent injury during a seizure, yet this was not adhered to.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was admitted with conditions including dementia and dysphagia, experienced a 15% weight loss over six months. The facility's policy required a Nutrition Alert for significant weight loss, but this was not initiated in a timely manner. The resident's weight was not adequately monitored, and the dietitian was not informed of the weight loss until a routine quarterly assessment. Despite the resident's plan of care including interventions like nutritional supplements and weekly weights, these measures were not effectively implemented or adjusted in response to the resident's ongoing weight loss. The dietitian noted that the resident had a healthy appetite and consumed meals well, yet the weight loss continued. The dietitian was not notified of the resident's weight changes documented in the weight log, and the issue of obtaining timely weights was an ongoing problem reported to the Director of Nursing. The lack of timely communication and intervention contributed to the resident's significant weight loss, as the dietitian was unaware of the situation until much later. The facility's failure to adhere to its weight monitoring policy and communicate effectively with the dietitian and healthcare proxy resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Maintain Oxygen Equipment and Change Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for two residents. For Resident #223, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator air filter to have a thick layer of gray fuzzy substance on it during multiple observations. Charge Nurse #1 was unaware of who was responsible for cleaning the filter or how often it should be cleaned. The Maintenance Director mentioned that a company was supposed to clean the filters weekly, but there was no documentation or system in place to track the cleaning of each machine. For Resident #53, who was admitted with chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator filter covered in a gray substance, indicating it had not been cleaned. Nurse Unit Manager #4 confirmed that the filter should be cleaned weekly and deferred to the maintenance department for ensuring the filters were cleaned. The Maintenance Director reiterated the lack of documentation and tracking system for the cleaning of the filters. Additionally, Resident #53's oxygen tubing was not changed as ordered. The tubing was dated 10/29/24, despite a physician's order to change it weekly. Resident #53 reported that nurses left new tubing for self-change, but there was no documentation of refusal or assessment of the resident's ability to change the tubing. Nurse #4 and the Director of Nursing confirmed that the tubing should be changed weekly and that residents should be assessed for their ability to change their own tubing, which had not been done for Resident #53.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning shared resident equipment, specifically the vital sign machine. According to the facility's policy, equipment should be cleaned immediately after use. However, a surveyor observed a nurse using a portable vital sign caddy on a resident under enhanced barrier precautions (EBP) and then using the same caddy on another resident without disinfecting it in between. During interviews, the nurse admitted to not disinfecting the equipment, acknowledging that she should have done so. The nurse unit manager confirmed that shared equipment should be disinfected before being used on another resident.
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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