Benjamin Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 120 Fisher Avenue, Boston, Massachusetts 02120
- CMS Provider Number
- 225654
- Inspections on file
- 23
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Benjamin Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that three shower rooms had malfunctioning door locks, unclean and musty conditions, visible mold, and nonfunctional ventilation systems. Personal hygiene items and soiled linens were left in the rooms, and water temperature controls were not working properly. Despite these issues, residents continued to use the showers, and facility leadership was unaware of the extent of the deficiencies.
A malfunctioning fire door alarm was removed and the door was secured with zip ties, blocking emergency egress for several days. Multiple staff were aware of the issue but did not escalate it to leadership. Additional fire doors also had non-functioning alarms, and surveillance cameras were not continuously monitored, resulting in an unsafe environment for residents, staff, and visitors.
Surveyors found that food was not kept frozen, expired and unlabeled food was present in storage, and dietary staff failed to follow proper hand hygiene and glove use. The dish machine was tested with expired strips, and sanitation buckets were not checked for correct sanitizer levels. The Food Service Director and DON were not aware of these issues until the survey.
Several residents and their representatives were not given the opportunity to participate in the development and implementation of person-centered care plans due to the facility's failure to conduct and document required interdisciplinary care plan meetings. This included residents with severe cognitive impairment and those with legal guardians, with no evidence of quarterly meetings or proper notification as outlined in facility policy.
Several residents with cognitive impairment and complex medical needs experienced significant weight loss and inadequate nutrition due to the facility's failure to complete required nutritional assessments, implement dietary and physician orders for supplements and fortified foods, and consistently obtain and document weights as ordered. Staff interviews revealed a lack of awareness and follow-through regarding these deficiencies.
The facility did not ensure that menus and meal preparation met the therapeutic dietary needs of residents, as staff lacked access to detailed menu breakdowns for specialized diets such as NAS, LCS, Low Fat, Low Potassium, and Low Lactose. Meals were often prepared based on available food rather than planned menus, and staff relied on tray tickets without clear guidance on food restrictions or portions for these diets.
Multiple residents experienced discrepancies between physician orders and care provided, including inaccurate documentation of NPO status, dietary supplements, oxygen administration, and use of compression stockings. Staff documented care as completed on the MAR and treatment records when it was not provided, and failed to follow or accurately record physician orders for several residents.
A resident with severe cognitive impairment and total dependence on staff was repeatedly observed without a call light due to a missing string, despite care plan instructions requiring call light accessibility. The resident reported the call light string frequently broke and had been unavailable for some time. Nursing staff and the DON confirmed all residents should have access to a call light, but were unaware of the issue.
A resident with severe cognitive impairment had inconsistencies between their MOLST form and active physician orders regarding advance directives, with the MOLST including multiple treatment preferences and the physician orders only reflecting DNR/DNI. Staff interviews confirmed that all documentation should be consistent, but the facility failed to ensure this, resulting in inaccurate documentation of the resident's treatment preferences.
Surveyors identified that three residents had inaccurate MDS assessments, including failure to document observed behaviors such as wandering and pacing, incorrect coding of discharge status for a resident sent home, and misclassification of a stage 4 pressure ulcer as stage 2 despite clinical documentation and staff observations. These inaccuracies were confirmed through record review, staff interviews, and direct observation.
Two residents did not have comprehensive, person-centered care plans implemented as required. One high-risk resident was repeatedly observed in bed without prescribed protective heel booties, despite care plan and physician orders, and reported not receiving assistance to put them on. Another resident requiring substantial ADL and transfer assistance had no care plan or physician orders specifying the level of help needed, and staff confirmed the absence of this information in the care documentation.
The facility failed to follow physician orders for two residents: one did not receive prescribed compression stockings for edema, and another did not receive weekly skin checks as ordered, with several checks omitted and incomplete wound documentation. The DON and nursing staff confirmed expectations for compliance with physician orders and proper documentation.
Two residents with significant physical and cognitive impairments did not receive the meal assistance and supervision specified in their care plans. Both were repeatedly observed eating alone in bed without staff present, despite documented needs for feeding help and supervision. Staff relied on verbal instructions rather than reviewing care plans, resulting in a lack of appropriate support during meals.
Two residents with cognitive impairment and high risk for skin issues did not receive proper skin assessments as required. Staff failed to identify, document, and report a visible bruise and a skin tear, and weekly skin checks were missed on multiple occasions, despite physician orders and facility policy. Nursing staff and the DON confirmed that these assessments and documentation were expected but not completed.
Two residents did not receive proper pressure ulcer care due to staff failing to follow wound care recommendations and physician orders. One resident with heel ulcers was repeatedly observed without required off-loading booties, while another resident with a back wound did not have a wound care order or treatment implemented as recommended. Nursing staff acknowledged lapses in documentation and order entry, resulting in deficiencies in wound management.
A resident with diabetes and peripheral vascular disease did not receive proper foot care, as staff failed to implement a physician-ordered bed cradle to keep bedding off the resident's feet and did not ensure timely podiatry follow-up. The resident was repeatedly observed with blankets resting on their feet, experienced ongoing pain, and staff inaccurately documented the use of the bed cradle. Nursing staff and the DON were unaware of the podiatry schedule and proper use of the bed cradle, resulting in inadequate care.
A resident with a g-tube and multiple comorbidities was made NPO and stopped receiving meal trays, resulting in weight loss. The RD was not notified of the change or involved in reassessing the resident's nutritional needs after the transition to NPO, and no updated evaluation was performed despite the resident's dependence on tube feeding for all nutrition and hydration.
Two residents requiring supplemental oxygen did not receive care according to professional standards, as their oxygen concentrator filters were not cleaned weekly and they received oxygen at higher flow rates than ordered by their physicians. Staff interviews confirmed that both the cleaning of equipment and adherence to physician orders were not followed.
A resident with PTSD and other mental health diagnoses did not have a comprehensive trauma-informed care plan, including identification of triggers, due to the absence of a social worker responsible for completing trauma assessments and care plans. Nursing staff and the DON confirmed that no trauma assessment or individualized PTSD care plan was present in the resident's record.
A resident with severe cognitive impairment and significant physical limitations was observed with four side rails in use on their bed, despite assessments indicating only two upper side rails were appropriate. Staff interviews revealed confusion about the correct number of side rails, and documentation lacked physician orders or care plan entries for the use of side rails. The DON confirmed that the use of four side rails was not in accordance with the resident's assessment.
The facility did not reassess a PRN psychotropic medication for a resident with severe cognitive impairment, allowing continued use without physician review, and also failed to complete an AIMS assessment for another resident receiving antipsychotic medication. Staff were unaware of the requirements for medication reassessment and AIMS completion.
Staff failed to follow Enhanced Barrier Precautions during wound care for two residents, including not wearing gowns and not posting required signage. Additionally, the facility lacked a documented water management plan to prevent Legionella and other waterborne pathogens, as confirmed by both the Maintenance Director and Infection Control Nurse.
The facility did not appoint a qualified Director of Food and Nutrition Services after the previous director resigned. A cook was assigned to manage the kitchen without the necessary qualifications or experience. The RD and DON confirmed the absence of a qualified FSD.
The facility did not conduct CORI checks for five new employees before they started working, as required by their policy. Two employees never had a CORI check, while three had checks completed after starting work. The DON confirmed that CORI checks must be done before employment begins.
The facility failed to develop and implement personalized care plans for three residents, resulting in deficiencies. A resident with a pacemaker lacked essential documentation in their care plan. Another resident did not have booties applied as ordered, and a third resident was not provided with adaptive utensils for meals. Staff interviews confirmed these oversights.
A resident with severe cognitive impairment experienced significant weight loss that was not addressed in a timely manner by the facility. Despite policies requiring immediate action for significant weight changes, the resident's weight loss was not confirmed until over a week later, and no intervention was implemented until two months after the weight loss reached clinical significance. The resident's weight stabilized only after the registered dietitian increased the frequency of a nutritional supplement.
Deficient Sanitation, Ventilation, and Safety in Resident Shower Rooms
Penalty
Summary
Surveyors identified multiple deficiencies in three resident shower rooms, including nonfunctional door locks, unclean and unsanitary conditions, and malfunctioning ventilation systems. Observations revealed that door locks were either difficult to operate or missing, with some doors left unlocked, allowing unrestricted access. The shower rooms were found to have musty odors, visible mold on ceilings, tiles, and shower curtains, and significant dust buildup on ventilation grills. In all three shower rooms, the ventilation systems were nonfunctional, as evidenced by the lack of airflow when tested with toilet paper. The Maintenance Director confirmed that the facility's HVAC system was not working throughout the building and that no professional remediation had been conducted for the mold, with only partial cleaning attempted by maintenance staff. Further inspection showed that personal hygiene items, towels, and residents' belongings were left in the shower rooms after use, contrary to facility expectations. Items such as damp towels, opened bottles of bathing products, and soiled linens were found on benches and floors, some with visible black or brown discoloration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the frequency of shower room cleaning and the status of the ventilation system. Despite the unclean conditions, documentation indicated that residents continued to use the showers, with several residents scheduled and reported to have received showers in the affected rooms. Additionally, water temperature issues were noted in at least one shower room, where the temperature remained cold and the gauge was not functioning properly. The Maintenance Director acknowledged that the water temperature gauge and pressure switch needed replacement and that shower water temperatures had not been included in daily audits since hot water was restored. The DON was aware of the water temperature issue but was not informed about the HVAC system's status or any plans for repair or replacement. These findings collectively demonstrate a failure to maintain a safe, functional, and sanitary environment in the resident shower rooms.
Fire Door Alarms Disabled and Egress Blocked, Creating Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors on the 2-West Unit, which had a census of 27 residents, including nine at risk for elopement. The alarm on the stairwell fire door malfunctioned, and instead of repairing it promptly, the alarm was removed and the door was secured shut with zip ties, preventing it from being used as an emergency exit for seven days. Multiple staff members, including nurses, security, and maintenance, were aware of the malfunction and the use of zip ties, but did not escalate the issue to facility leadership in a timely manner. The Director of Nurses and Administrator were not informed until several days later, despite being present in the facility during the period the door was zip tied shut. Further observations revealed that other fire doors throughout the facility also had non-functioning alarms, and at least one fire door did not self-close as required. The facility's posted protocols and policies required that all egress paths remain unobstructed and that accident hazards be identified and removed, but these were not followed. Staff interviews confirmed that the malfunctioning alarms and the use of zip ties were known to several employees, but there was no effective communication or tracking system in place to ensure timely repairs or to alert leadership to the safety hazard. Additionally, surveillance security cameras intended to monitor resident safety were not being continuously monitored by staff, as observed on multiple occasions. The Administrator confirmed that it was her expectation that these cameras be monitored 24/7, and acknowledged that the fire doors should have functioning alarms and be able to close properly. The lack of monitoring and failure to maintain functional fire safety systems contributed to an unsafe environment for residents, staff, and visitors.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. The walk-in freezer was found to be operating at temperatures above freezing, with the thermometer reading 30 to 40 degrees Fahrenheit and food items such as shrimp, crabmeat, and pasta observed to be soft and not frozen. Despite temperature logs indicating appropriate freezing temperatures, staff confirmed that the food had been soft for some time and that the logs did not match their observations. The Maintenance Director had been monitoring the freezer due to ongoing mechanical issues but did not document repairs, and the Food Service Director was not notified of the problem until the surveyor's visit. In the dry storage area, several food items were found to be improperly labeled, undated, or expired. Open bags of split peas, rice, pasta, and taco shells were not dated when opened or securely stored, and some items, such as food coloring, were significantly past their expiration date. The Registered Dietician confirmed that all food items should be labeled with the date opened, stored securely, and not be expired. Dietary staff were observed failing to follow proper hand hygiene and glove use protocols. One cook was seen touching ready-to-eat food, his clothing, and various surfaces without changing gloves or washing hands between tasks. Diet Aids were observed washing their hands but then turning off the faucet with clean hands, potentially re-contaminating them. Additionally, the dish machine was being tested with expired and incorrect test strips, and sanitation buckets used for cleaning were not being tested to ensure proper sanitizer concentration. The Food Service Director was unaware of these lapses until informed by the surveyor.
Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were allowed to participate in the development and implementation of person-centered care plans by not conducting interdisciplinary care plan meetings as required. Multiple residents, including those with severe cognitive impairment and those with legal guardians, did not have documented evidence of quarterly care plan meetings or participation by their representatives. For example, one resident with Alzheimer's Disease and a legal guardian had no documentation of care plan meetings in either the paper or electronic medical record, aside from a single note indicating an attempt to schedule a meeting with the guardian. Other residents, including one with hemiplegia and another with severe cognitive impairment, also lacked documentation of care plan meetings within the past year. Interviews with the Director of Nursing revealed uncertainty regarding the scheduling and requirements for care plan meetings, and it was confirmed that if such meetings had occurred, they would be documented in the medical record. The facility was without a social worker at the time of the survey, further contributing to the lack of care plan meeting documentation and resident participation. Facility policies require that residents and their representatives be encouraged to participate in care planning, with advance notice provided and records maintained of such notices. The interdisciplinary team is responsible for developing individualized care plans, and every effort should be made to schedule meetings at convenient times for residents and families. Despite these policies, the facility did not maintain records or evidence that these requirements were met for several residents, resulting in a deficiency related to resident participation in care planning.
Failure to Maintain Nutrition and Hydration Status Due to Incomplete Assessments and Unimplemented Dietary Orders
Penalty
Summary
The facility failed to maintain adequate nutrition and hydration for several residents, as evidenced by multiple instances of unaddressed weight loss, incomplete nutritional assessments, and failure to follow physician and dietary orders. One resident with Alzheimer's disease and severe cognitive impairment experienced significant and ongoing weight loss after admission. Despite documented weight loss and poor oral intake, the resident's nutritional supplement was reduced from three times daily to once daily without documented rationale, and the dietitian did not complete the required quarterly assessment. The dietitian was unaware of the most recent weight loss and could not explain the reduction in supplement calories, while the MAR did not indicate any refusal of supplements by the resident. Another resident with a history of diabetes and cognitive impairment did not consistently receive double portions or fortified foods as ordered, and weights were not obtained weekly as prescribed. Observations showed that the resident's meal portions were not increased as required, and fortified foods were not prepared according to the facility's standards. The dietitian and food service director were unclear about the implementation of dietary interventions, and the dietitian had not evaluated the resident following a significant weight loss after hospitalization, despite a physician's order for a nutritional consult. A third resident with a feeding tube and severe cognitive impairment did not have quarterly nutrition assessments completed for over eight months, contrary to facility policy and the dietitian's stated practice for high-risk residents. Additionally, another resident with multiple chronic conditions had a physician's order for weights every three weeks, but weights were not consistently obtained or documented, and the MAR indicated weights were signed off without corresponding records. Staff interviews confirmed a lack of awareness and adherence to these orders, and the DON stated that such orders should be followed and the physician notified if weights are not obtained.
Failure to Provide Menus and Meals Meeting Residents' Therapeutic Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were provided in accordance with established nutritional standards and did not meet the specific dietary needs of residents. Observations and interviews revealed that menus were not consistently followed, and staff often prepared meals based on available food rather than the planned menu. The menus provided to kitchen staff did not include detailed therapeutic breakdowns for specialized diets such as No Added Salt (NAS), Low Concentrated Sugar (LCS), Low Fat, Low Potassium, and Low Lactose diets, despite a significant number of residents requiring these modifications. Staff interviews indicated a lack of clarity and resources regarding which menu week was being used, and the absence of therapeutic diet information on the menus. The Food Service Director and kitchen staff reported that they relied on resident tray tickets for diet orders but did not have guidance on specific food restrictions or portion sizes for specialized diets. Additionally, there were instances where meals served did not align with the planned menu due to food shortages or equipment issues, further compromising the ability to meet residents' dietary needs. The Registered Dietician confirmed that the menus lacked the necessary therapeutic breakdowns and emphasized the importance of providing and following diet orders for residents with conditions such as hypertension, congestive heart failure, and diabetes. The Food Service Director acknowledged that therapeutic diets were not in place when he started and that the current system did not support the provision of appropriate meals for residents with specialized dietary requirements.
Inaccurate Medical Record Documentation and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, resulting in discrepancies between physician orders, documentation, and actual care provided. For one resident with severe cognitive impairment and an NPO (nothing by mouth) order, staff continued to document the administration of a diabetic snack at bedtime on the Medication Administration Record (MAR), despite the resident not receiving anything by mouth. Interviews with nursing staff and the Director of Nursing confirmed that the snack should not have been documented as given after the NPO order was in place. Another resident, who was dependent on staff for care and had an order for a dietary supplement with all meals, was observed eating without the supplement present on their tray. The MAR, however, indicated the supplement was administered, and there was no documentation of refusal. Nursing staff confirmed the supplement should have been provided per the physician's order. Additionally, two residents with orders for specific oxygen settings were observed receiving oxygen at higher flow rates than ordered, and their MARs failed to document oxygen use as required. Nursing and administrative staff acknowledged that oxygen should be administered and documented according to physician orders. A further deficiency was noted for a resident with an order for bilateral compression stockings, who was observed without them on multiple occasions. Despite this, the treatment administration record was marked as if the order had been completed. The Director of Nursing stated that all orders should be followed as written and not marked as complete if not actually performed. These findings demonstrate a pattern of inaccurate documentation and failure to follow physician orders for several residents.
Failure to Provide Call Light to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of prostate cancer was found without access to a call light, as observed during multiple survey days. The resident, who is dependent on staff for daily tasks, was seen lying in bed without a call light, and it was noted that the call light string was missing from the wall. The resident reported that the call light string often breaks and that they had been without a call light for some time, expressing a desire to have one to call for help. Review of the resident's fall care plan indicated that the call light should be within reach and answered promptly. Interviews with nursing staff and the DON confirmed that all residents should have access to a call light, and staff were unaware that this resident's call light was broken.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were accurately and consistently documented for a resident with severe cognitive impairment. Record review showed discrepancies between the resident's MOLST form, which included orders for Do Not Resuscitate (DNR), intubation, ventilation, noninvasive ventilation, transfer to hospital, dialysis, artificial nutrition, and hydration, and the active physician orders, which only indicated DNR and Do Not Intubate (DNI). The resident's care plan referenced following the MOLST and noted a legal guardian was in place, but did not clarify the inconsistencies between the MOLST and physician orders. Interviews with nursing staff and the Director of Nurses confirmed that the MOLST form should be signed by the resident or health care proxy and that all medical record documentation, including physician orders, should match the MOLST form. However, the facility did not ensure that the resident's code status and advance directives were consistently documented across the medical record, leading to a deficiency in honoring the resident's right to have their treatment preferences accurately reflected.
Inaccurate MDS Assessments for Resident Behaviors, Discharge Status, and Pressure Ulcer Staging
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to the assessment and documentation of resident conditions and behaviors. For one resident with severe cognitive impairment and a history of pacing and wandering, the MDS assessment did not reflect the documented and observed behaviors of intrusive wandering and pacing, despite consistent documentation of these behaviors in the medical record and observations by staff. The Director of Nursing confirmed that these behaviors should have been coded on the MDS if they were occurring during the look-back period. Another resident was discharged home, but the discharge MDS was incorrectly coded as a planned discharge to an acute hospital. The Director of Nursing confirmed that the resident was discharged home and that the MDS should have been coded accordingly. The MDS Coordinator was not available for interview regarding this discrepancy. A third resident with a long-standing stage 4 pressure ulcer was incorrectly coded on the MDS as having a stage 2 pressure ulcer. Medical records and wound consultant notes indicated the presence of a stage 4 pressure ulcer, and staff interviews confirmed the wound had improved but was still present. The Director of Nursing stated the wound was now a stage 2 ulcer, which was why it was coded as such, despite clinical standards requiring that a healing stage 4 ulcer continue to be documented as stage 4 until fully healed.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident, admitted with lack of coordination, hemiplegia, and a need for personal assistance, was identified as being at very high risk for pressure ulcer development, with a Norton score of 7. Despite physician orders and a care plan intervention to apply protective heel booties while in bed, multiple observations showed the resident lying in bed without the booties, which were instead found on the wheelchair. The resident reported typically wearing the booties but stated that no one had assisted with putting them on that day. Interviews with nursing staff and the DON confirmed that care plans and orders should be followed as written, and that the resident should have the booties on at all times when in bed. Another resident, admitted with diagnoses including diabetes, adult failure to thrive, pain, and acute embolism and thrombosis of the deep veins, was found to have no care plan addressing Activities of Daily Living (ADLs) despite requiring substantial to maximal assistance for ADLs and transfers. Review of the resident's care plan and physician orders revealed no documentation regarding the level of assistance needed for ADLs, transfers, or eating. Staff interviews confirmed that the CNA Kardex, which should reflect the care plan, did not indicate the required level of assistance, and that an ADL care plan should be in place for all residents to guide staff in providing appropriate care.
Failure to Follow Physician Orders for Compression Stockings and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. One resident, admitted with diabetes with polyneuropathy, edema, and weakness, had a physician's order for bilateral knee-length compression stockings to be applied in the morning for edema. Multiple observations over two days showed the resident out of bed and in bed without the prescribed compression stockings. The DON stated she was unaware of the order and expected all physician orders to be followed as written. Another resident, admitted with hemiplegia, hemiparesis, and an anoxic brain injury, had a physician's order for weekly skin assessments due to high risk for skin breakdown and a history of pressure ulcers. Review of the medical record revealed that nine weekly skin checks were omitted over a three-month period, and the two most recent checks lacked documentation describing the wound. Interviews with nursing staff and the DON confirmed that weekly skin checks should be completed and documented, including full assessment of the skin and wounds.
Failure to Provide Required Assistance with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents who required help with eating, as observed and documented by surveyors. One resident, admitted with diagnoses including dysphagia, feeding difficulties, lack of coordination, and hemiplegia, was assessed as cognitively intact but required substantial to maximal assistance with self-feeding. Despite care plans indicating the need for feeding assistance and built-up silverware, this resident was repeatedly observed eating alone in bed, with food being spilled during attempts to self-feed. Staff interviews revealed a lack of awareness regarding the resident's care plan, with reliance on verbal instructions rather than documented interventions. Another resident, with severe cognitive impairment and dependence for all self-care activities, was also observed eating alone in bed without staff supervision or assistance, despite care plans specifying the need for supervision and assistance during meals. Staff interviews indicated that after meal setup, the resident was left to eat independently, contrary to the care plan requirements. The Director of Nursing confirmed that care should be provided as indicated in the care plans, but both residents did not receive the level of assistance documented as necessary for their conditions.
Failure to Identify and Document Skin Changes and Complete Weekly Skin Checks
Penalty
Summary
The facility failed to ensure proper identification and documentation of skin changes for two residents, resulting in deficiencies in the standard of care. For one resident with diagnoses including depression, diabetes, and dementia, staff did not identify or document a visible bruise on the right forearm during weekly skin checks, despite multiple observations by surveyors and staff interviews confirming the presence of the bruise. The resident was dependent on staff for daily care and had a care plan requiring regular skin checks and reporting of skin changes. However, weekly skin assessments repeatedly documented the skin as intact, and staff failed to report or document the bruise, even after it was observed by several staff members and the surveyor. For another resident with Alzheimer's disease and severe cognitive impairment, a skin tear was observed on the right arm, but the injury was not documented on the skin check as required. The resident was known to have fragile skin and was at high risk for skin tears, with protective measures in place. Despite this, the skin tear was not recorded during the skin assessment, and staff interviews revealed that the injury could have been missed if protective sleeves were worn. Additionally, the resident's medical record showed that weekly skin checks were missed on four occasions over two months, contrary to physician orders and facility policy. Interviews with nursing staff and the Director of Nursing confirmed that all skin impairments should be documented and reported, and that weekly skin checks are expected to be completed as ordered. The Director of Nursing was unaware of the missed skin checks and stated that any observed skin area should be included in the weekly documentation. The failure to identify, document, and report skin changes and to complete weekly skin checks as ordered led to the deficiencies cited in the report.
Failure to Follow Pressure Ulcer Care Protocols and Implement Wound Treatments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident with bilateral heel pressure ulcers, staff did not consistently follow physician orders and wound care recommendations to off-load the heels using protective booties while in bed. Multiple observations showed the resident's heels resting directly on the mattress without the prescribed booties, despite clear orders and recommendations from the wound physician to off-load the wounds and use heel-relieving devices. The resident was also noted to have significant pain in one heel during these observations. For another resident who was re-admitted with a lower back pressure wound, the facility did not implement the recommended wound treatment as outlined in the hospital discharge summary. The resident's records lacked a physician order for wound care, and the Treatment Administration Record (TAR) did not reflect any wound treatment being provided. The plan of care also failed to include wound care interventions. Nursing staff acknowledged that the wound order was missed and not entered until several days after re-admission, despite being aware of the open area. Interviews with nursing staff and the DON confirmed that wound care recommendations and documentation protocols were not followed as required by facility policy. Staff stated that new wounds should be measured, documented, and reported to the physician, with appropriate treatment orders implemented, but these steps were not consistently carried out for the affected residents.
Failure to Provide Proper Foot Care and Implement Physician Orders
Penalty
Summary
A resident with a history of diabetes, peripheral vascular disease, and left foot pain was not provided with appropriate foot care in accordance with professional standards. Despite having physician orders for a bed cradle to prevent bedding from resting on the resident's feet and referrals for podiatry and vascular evaluations, the resident was repeatedly observed with blankets directly on their feet and heels on the mattress. The bed cradle, intended to alleviate pain and prevent further complications, was not in use as ordered, and staff were unaware of how to use it or failed to offer it to the resident. Documentation on the Treatment Administration Record inaccurately indicated that the bed cradle was in use every shift, even though it had only recently arrived and was not being applied as required. The resident expressed ongoing pain and concern about their feet, specifically noting a blackened toenail and edema, which were observed by the surveyor. The medical record showed only one podiatry visit since admission, despite ongoing orders for podiatry care. Interviews with nursing staff and the DON confirmed a lack of clarity regarding podiatry visits and the use of the bed cradle, as well as improper documentation practices. These actions and inactions resulted in the resident not receiving the necessary foot care and interventions to maintain foot health and prevent complications related to their medical conditions.
Failure to Notify Dietician and Reassess Tube Feeding After Change to NPO Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services were provided in accordance with professional standards for a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses including type 2 diabetes mellitus, dementia, and failure to thrive, was admitted with orders for both enteral feeding and a puree diet. Over time, the resident became NPO (nothing by mouth) following a speech language pathologist's evaluation, and meal trays were discontinued. Despite this significant change in nutritional status and a documented weight loss, the registered dietician (RD) was not notified or involved in reassessing the resident's nutritional needs after the change to NPO status. The medical record review showed that the RD had only completed an initial assessment upon admission and had not evaluated the resident after the transition to NPO or in response to the observed weight loss. The RD stated she was unaware of the resident's change to NPO status and the associated weight loss, and indicated she would have wanted to be informed to assess for any necessary changes in the tube feeding regimen. The DON confirmed that the RD should have been made aware of the change and evaluated the resident accordingly. Documentation of the resident's meal intake percentages was requested but not provided. Observations and interviews confirmed that the resident was frail, dependent on staff for all care, and received all nutrition and hydration via the g-tube. The failure to notify the RD and to provide timely reassessment after a significant change in nutritional status and intake constituted a lapse in following professional standards of care for residents with feeding tubes.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure professional standards of practice in providing respiratory care for two residents who required supplemental oxygen. For both residents, surveyors observed that the oxygen concentrator filters were covered with a layer of gray dust over multiple days, indicating that the filters had not been cleaned as required. According to staff interviews, the filters should be cleaned weekly in conjunction with the changing of oxygen tubing, but this was not done for either resident. Additionally, both residents were receiving oxygen at flow rates higher than those ordered by their physicians. One resident, with severe cognitive impairment and a history of rheumatoid arthritis and oxygen dependence, was observed receiving oxygen at 4 liters, despite a physician order for 2 liters as needed to maintain oxygen saturation above 92%. The other resident, with moderate cognitive impairment and diagnoses including acute respiratory failure and chronic heart failure, was observed receiving oxygen at 3 liters, while the physician order specified 2 liters as needed for oxygen saturation below 90%. These failures were confirmed through record review and staff interviews.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for trauma informed care for one resident with a history of trauma, specifically for a resident diagnosed with PTSD, major depressive disorder, conversion disorder, and anxiety. The resident was cognitively intact and had an active diagnosis of PTSD, as indicated by the most recent MDS assessment. Record review showed that there was no care plan addressing PTSD, no identification of individualized triggers, and no completed trauma assessment in the resident's medical record. Interviews with nursing staff and the DON confirmed that the social worker, who is responsible for trauma assessments and PTSD care plans, had not been available for several weeks, resulting in the absence of the required care plan and assessment.
Failure to Implement Bed Rail Use According to Assessment and Policy
Penalty
Summary
The facility failed to ensure that side rails were implemented according to the resident assessment for one resident out of a sample of 24. The facility's policy requires that bed rails be used only after evaluation, care planning, and informed consent, with the least restrictive device chosen. For the resident in question, who was admitted with hemiplegia, hemiparesis, and an anoxic brain injury and assessed as having severe cognitive impairment, observations showed that four side rails were consistently in use on the bed, despite the assessment indicating only two upper side rails should be used. Multiple observations over several days confirmed the use of all four side rails, regardless of the resident's activity or position in bed. Review of the resident's side rail assessments, care plan, and physician orders revealed that only two upper side rails were indicated, and there was no documentation supporting the use of four side rails. Interviews with nursing staff and a CNA indicated a lack of awareness regarding the correct number of side rails to be used, with staff attributing the use of four side rails to the family having purchased the bed. The DON confirmed that only two side rails should be in use according to the assessment and that a physician's order and care plan should be in place for side rail use, which were absent.
Failure to Reassess PRN Psychotropic Medication and Complete AIMS Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medications by not reassessing a PRN psychotropic medication as required. Specifically, a resident with severe cognitive impairment and diagnoses including depression and Alzheimer's Disease had a PRN order for trazodone to address restlessness and agitation. The order, initiated at admission, was not reassessed by the physician after the initial 14 days or at any subsequent time, despite ongoing use over several months. There was also no evidence that the resident was seen by behavioral health services for medication management. Facility staff, including the nurse and Director of Nursing, were unaware that the medication had not been re-evaluated as required by policy. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for another resident who was receiving antipsychotic medication. This resident, admitted with diagnoses including suicidal ideations, depression, aphasia, and chorea, had a physician's order for daily risperidone. Review of the medical record showed no documentation that an AIMS assessment was completed, as required for residents on antipsychotic medications. Staff interviews revealed a lack of awareness and training regarding the completion and timing of AIMS assessments.
Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in the implementation of Enhanced Barrier Precautions (EBP) and the absence of a water management plan. Specifically, during wound care for a resident, a nurse did not wear a gown as required by EBP protocols, despite signage indicating the need for such precautions and the availability of gowns and gloves outside the resident's room. The nurse acknowledged the omission, and the Director of Nurses confirmed that residents with wounds require both gown and glove use during dressing changes. In a separate instance, another resident with a wound did not have EBP signage posted on their doorway, and a nurse performed a dressing change using only gloves, omitting the gown. Both the nurse and the Director of Nurses recognized that EBP should have been implemented and followed for this resident. Additionally, the facility did not have documentation or a plan in place to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. Both the Maintenance Director and the Infection Control Nurse were unable to provide a water management plan when requested. The CDC guidelines referenced in the report recommend comprehensive water management programs to reduce the risk of Legionella growth and transmission, but the facility lacked evidence of such measures.
Lack of Qualified Food Service Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services (FSD) after the previous FSD resigned in September 2023. Dietary staff #1, who was employed as a cook, was delegated responsibilities such as ordering food, scheduling staff, and conducting staff in-services in the absence of a qualified FSD. However, Dietary staff #1 did not possess the necessary certification for food service management, an associate's or higher degree in food service management or hospitality, nor two or more years of experience in the position of a Director of Food and Nutrition Services in a nursing facility setting. The Registered Dietitian (RD), who worked at the facility two days a week, confirmed that Dietary staff #1 was managing the kitchen without the appropriate credentials or qualifications. The Director of Nursing (DON) also acknowledged that the facility had not replaced the previous FSD and expected the staff managing the food service department to meet the minimum qualifications for the role.
Failure to Conduct Timely CORI Checks for New Employees
Penalty
Summary
The facility failed to conduct Criminal Offender Record Information (CORI) checks for five employees before their employment commenced, as required by their Abuse Program Policy and Procedure. This policy mandates that potential employees undergo a criminal background check, and those with negative findings should not be hired. Upon reviewing the employee files of the five most recent hires, it was found that two employees never had a CORI check completed, yet they were allowed to work at the facility. Additionally, three employees had their CORI checks completed only after they had already started working. During an interview, the Director of Nursing confirmed that CORI checks must be completed prior to any employee beginning work at the facility.
Deficiencies in Personalized Care Plans and Implementation
Penalty
Summary
The facility failed to develop and implement personalized care plans for three residents, leading to deficiencies in their care. For one resident with a pacemaker, the facility did not document essential information such as the paced rate, serial number, type of pacemaker, cardiologist information, or frequency of pacer checks in the care plan. This oversight was confirmed during interviews with nursing staff, who were unaware of the necessary details to include in the care plan. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, did not have booties applied as per the physician's order. Observations over several days showed the resident without the prescribed booties, and the facility's records did not indicate monitoring of the booties' application. Additionally, a third resident, who was cognitively intact but dependent on staff for self-care, was observed eating without the built-up handled utensils specified in their care plan and physician's order. Interviews with staff confirmed that these adaptive utensils were not consistently provided with the resident's meal trays.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to a clinically significant weight loss that was not addressed in a timely manner. The resident, who had severe cognitive impairment and was not on a physician-prescribed weight loss regimen, experienced a weight loss of 5.6% in one month and 6% over the following two months. Despite the facility's policy requiring immediate reweighing and notification of the dietitian for significant weight changes, the resident's weight loss was not confirmed until over a week later, and no intervention was implemented until two months after the weight loss reached clinical significance. The resident's care plan indicated increased nutrient needs due to a significant weight loss of 12.4% since August 2023. The resident's weight stabilized only after the registered dietitian assessed the situation and recommended increasing the frequency of a nutritional supplement. Interviews with facility staff revealed that the resident had a variable appetite and had experienced weight loss in the past. The registered dietitian expected nursing staff to notify her of significant weight changes, but the resident's weight loss was not addressed promptly, resulting in further weight loss before stabilization.
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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