Blackstone Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitinsville, Massachusetts.
- Location
- 447 Hill Street, Whitinsville, Massachusetts 01588
- CMS Provider Number
- 225312
- Inspections on file
- 21
- Latest survey
- May 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Blackstone Valley Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not request updated Level II PASARR evaluations for two residents who experienced significant changes in psychosocial condition, including suicidal ideation and emergency mental health interventions, despite initial screenings indicating no need for further review. This failure to coordinate assessments and refer for services as needed was confirmed by staff interviews and record review.
A resident with COPD and chronic pain syndrome, who was cognitively intact, was not provided the opportunity to participate in required quarterly care plan meetings. Facility records lacked evidence of care plan meetings, participation, or documentation of refusals, and staff confirmed that the meetings were not held or documented as required.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and elopement risk was not included in the facility's Elopement Risk Binder as required, and another cognitively intact resident was found storing smoking materials in their walker, with a missed quarterly Safe Smoking Assessment. Staff interviews and record reviews confirmed lapses in following facility policies for both elopement risk management and safe smoking practices.
A resident with multiple medical conditions and at nutritional risk experienced significant, severe weight loss over several weeks without receiving a required nutritional assessment or timely intervention from the dietician. Despite facility policy requiring prompt assessment and action for notable weight changes, staff failed to communicate the issue or implement appropriate care, resulting in unaddressed nutritional decline.
Two residents receiving oxygen therapy were found to have oxygen concentrator filters covered in thick dust, despite documentation indicating weekly cleaning. Both residents, one with severe cognitive impairment and another with chronic heart failure, were observed using equipment that had not been properly maintained according to physician orders, manufacturer guidelines, and facility policy. Nursing staff confirmed the filters should have been cleaned but acknowledged this was not done.
A resident with dementia and CKD did not have timely responses or implementation of repeated Consultant Pharmacist recommendations, including obtaining a Vitamin D level and discontinuing Loratadine. Despite provider agreement, actions were delayed for months, and required documentation of MRRs was missing from the clinical record.
A resident with dementia and chronic kidney disease continued to receive Loratadine for over three months after the provider had agreed to discontinue it, despite repeated recommendations from the Consultant Pharmacist and established procedures for implementing such orders. The DON confirmed that the medication was not discontinued as directed, and could not provide a reason for the delay.
Surveyors found that two residents received incorrect medication dosages or forms, resulting in a medication pass error rate of 6.9%, which is above the acceptable 5% threshold. Errors included administering a tablet instead of an oral solution via G-Tube and giving double the prescribed dose of Fish Oil. Nursing staff acknowledged the errors during interviews.
Surveyors found that multiple food items in the main kitchen walk-in refrigerator, including ham salad, cubed chicken, and various vegetables, were stored without required labels or dates. The Food Service Director confirmed that these items should have been labeled and dated per facility policy and FDA Food Code, but were not, resulting in a failure to follow proper food safety and sanitation standards.
A resident with bilateral knee osteoarthritis did not receive a timely PT evaluation as ordered by a physician, despite ongoing pain and a referral for therapy. The resident was only approached once for PT, which was not completed due to illness, and was instead evaluated by OT without assessment of knee pain or stiffness. There was no evidence the resident was re-approached for PT after recovery, and staff interviews confirmed the PT evaluation was not completed as ordered.
A nurse failed to clean and disinfect a blood glucose monitor after using it on a resident and before returning it to the medication cart with other clean equipment. This action was not in accordance with facility policy, which requires all shared medical equipment to be disinfected between uses to prevent the spread of infection.
Failure to Update PASARR Assessments After Significant Psychosocial Changes
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were requested for two residents following significant changes in their psychosocial conditions that required emergency mental health interventions. For one resident with diagnoses including Anxiety Disorder, Depression, and PTSD, the initial Level I PASARR screen was negative, and no Level II evaluation was deemed necessary at admission. However, the resident later exhibited suicidal ideation on two separate occasions, resulting in transfers to the emergency department for further evaluation. Despite these significant changes, the facility did not update or resubmit the Level I PASARR for an additional review and Level II evaluation. Another resident, admitted with Major Depressive Disorder, Anxiety, and Depression, had a Level I PASARR indicating a history of mood and anxiety disorders, and a Level II determination that no further PASARR involvement was required. This resident subsequently made multiple statements about suicidal ideation, leading to hospital admissions for evaluation and observation. The facility did not report these changes in status to the PASARR office, as confirmed by the social worker. The failure to coordinate updated PASARR assessments following these acute psychosocial events constituted the deficiency.
Failure to Conduct and Document Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was provided the right to participate in the care plan process, as required by facility policy. Specifically, the facility did not conduct quarterly care plan meetings for a resident with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic pain syndrome, who was cognitively intact at the time of the deficiency. The facility's policy requires that residents and their families be invited to participate in care planning conferences, with advance notice, documentation of attendance, and follow-up if the resident or representative cannot attend. Record review showed no evidence that the required care plan meetings were held or that the resident or their representative participated in the process for the scheduled quarters. There was also no documentation of any refusals to participate or of any contact made to review the care plan information with the resident or representative. Interviews with facility staff confirmed that the meetings were not held as scheduled and that there was no documentation to support that the care planning process was followed for the resident during the specified periods.
Failure to Prevent Accident Hazards Related to Elopement and Smoking Materials
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, resulting in deficiencies related to elopement risk management and safe smoking practices. One resident with severe cognitive impairment, dementia, and anxiety disorder was identified as an elopement risk upon admission, with behaviors such as wandering, expressing a desire to go home, and staying near exits. Although the facility's policy required that residents at risk for elopement be included in an Elopement Risk Binder with their photograph and information, this resident was not added to the binder at the front desk or nurses' stations. Staff interviews confirmed that the resident's risk evaluation was not properly completed to indicate inclusion in the binder, and the required documentation and photograph were missing. Another resident, who was cognitively intact and a smoker, was found to have smoking materials, including a cigarette box, lighter, and used cigarettes, stored in the compartment of a rolling walker in their room. Facility policy required that all smoking materials be kept at the nurses' station and disposed of properly after use to prevent fire hazards. Staff confirmed that the resident should not have had smoking materials in their possession and that storing them in the walker was a fire hazard. Additionally, the facility failed to complete a required quarterly Safe Smoking Assessment for this resident, as indicated by a gap in the assessment schedule between two documented assessments. These deficiencies were identified through record reviews, staff and resident interviews, and direct observation. The facility's failure to follow its own policies regarding elopement risk management and safe smoking practices resulted in lapses in supervision and the presence of accident hazards for the affected residents.
Failure to Complete Nutritional Assessment and Intervene for Significant Weight Loss
Penalty
Summary
Facility staff failed to provide appropriate nutritional care and services for a resident identified as being at risk for altered nutrition status. Upon admission, the resident, who had diagnoses including Multiple Sclerosis, dysphagia, and Major Depressive Disorder, did not receive a required nutritional assessment by the dietician. The facility's policy mandates that a nutritional assessment be completed within a day or two of admission and that significant weight changes be documented and addressed. Despite the resident experiencing a significant and severe weight loss over several weeks, there was no evidence in the clinical record that a nutritional assessment was completed or that the dietician made any recommendations or interventions. The resident's weight records showed a 7.5% to 9.8% weight loss over a short period, which met the facility's criteria for severe weight loss. Although the care plan identified the resident as being at nutritional risk and included interventions such as monitoring meal intake and obtaining lab work, there was no documentation of follow-up or action taken in response to the weight loss. Interviews with facility staff revealed that the dietician was unaware of the resident's weight loss and had not reviewed the weight records, and the unit manager was not informed of the issue. The lack of communication and failure to follow established protocols led to the deficiency in providing adequate nutrition and monitoring for the resident.
Failure to Maintain Clean Oxygen Concentrator Filters for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including encephalopathy and obstructive sleep apnea, the oxygen concentrator's air intake gross particle filter was repeatedly observed with a thick coating of dust on multiple occasions. Despite physician orders and documentation indicating weekly cleaning of the filter, the filter remained visibly soiled, and the resident reported ongoing difficulty breathing. Additionally, a bottle of sterile water intended for use with the concentrator was found on the floor rather than in its designated storage area. For another resident with chronic diastolic heart failure and moderate cognitive impairment, the oxygen concentrator's removable filter was also observed to be covered in a thick layer of gray dust over several days. This resident used oxygen therapy primarily at night and expressed concern about the cleanliness of the equipment, stating reluctance to breathe through a visibly dirty filter. Documentation indicated that the filter was supposed to be cleaned weekly, but observations contradicted these records, showing a lack of proper maintenance. Interviews with nursing staff confirmed that the filters should have been cleaned weekly in accordance with both manufacturer guidelines and facility policy, but acknowledged that this had not occurred. The failure to maintain clean and sanitary oxygen concentrator filters as required by physician orders, manufacturer instructions, and facility policy resulted in the equipment being left in a condition that could compromise its function and the quality of care provided to the residents.
Failure to Timely Respond to and Implement Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely response and implementation of Medication Regimen Review (MRR) recommendations for a resident with dementia and chronic kidney disease. The Consultant Pharmacist made repeated recommendations to obtain a Vitamin D level on three separate occasions, but there was no documented evidence that the initial recommendation was reviewed or responded to by the provider. Although the provider eventually agreed to the recommendation, the Vitamin D level was not obtained until after multiple MRRs and provider consents. Additionally, the facility failed to maintain documentation of the MRRs in the resident's clinical record as required by policy. Repeated recommendations were also made by the Consultant Pharmacist to discontinue Loratadine, an antihistamine medication, over several months. While the provider agreed to discontinue the medication, there was no evidence that the order was implemented until several months later. The Director of Nursing was unable to provide documentation for several MRRs and could not explain the delay in discontinuing the medication after provider agreement. The process for handling MRRs involved emailing recommendations to the Unit Manager and placing them in the Provider's Communication Book, but this process did not ensure timely review or implementation of the pharmacist's recommendations.
Failure to Discontinue Unnecessary Medication After Provider Approval
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease was admitted to the facility and was prescribed Loratadine, an antihistamine medication. The Consultant Pharmacist made repeated recommendations to discontinue Loratadine, which were communicated to both the provider and nursing staff over several months. On 10/8/24, the provider agreed with the recommendation to discontinue the medication, and this agreement was documented in the resident's clinical record. Despite this, the resident continued to receive scheduled doses of Loratadine for over three months, as indicated by the Medication Administration Records, until the medication was finally discontinued on 2/4/25. The Director of Nursing (DON) confirmed during interviews that the process for handling Consultant Pharmacist recommendations involved emailing the Unit Manager, printing the recommendations, and placing them in the Provider's Communication Book. The DON stated that nursing staff were expected to check the communication book every shift and implement provider-approved orders immediately. However, the DON was unable to explain why the Loratadine was not discontinued as ordered, acknowledging that the medication continued to be administered unnecessarily after the provider had agreed to stop it.
Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5%, resulting in a 6.9% error rate during the survey. This deficiency was identified through observation, interview, and record review, where two residents out of five applicable residents experienced medication administration errors out of 29 opportunities. The facility's policies required adherence to the Five Rights of Medication Administration and safe medication practices, but these were not followed in the observed incidents. One resident with a history of cerebral infarction, hemiplegia, dysphagia, and failure to thrive was ordered to receive Ferrous Sulfate Oral Solution via G-Tube, but was instead administered a crushed Ferrous Sulfate tablet. The nurse acknowledged the error during an interview. Another resident with diagnoses including normal pressure hydrocephalus, Parkinson's Disease, heart disease, and dementia was ordered to receive two 500 mg Fish Oil capsules (total 1000 mg) but was given two 1000 mg capsules (total 2000 mg). The nurse also confirmed the error during an interview. These actions directly led to the facility exceeding the acceptable medication error rate.
Failure to Label and Date Food Items in Main Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the main kitchen. Specifically, multiple food items stored in the walk-in refrigerator—including ham salad, cubed chicken, halved tomatoes, sliced cucumbers, and diced onions—were found to be unlabeled and undated. These observations were made during a walkthrough with the Food Service Director (FSD), who confirmed that all food items should have been labeled and dated according to facility policy and FDA Food Code requirements. The facility's policy and the FDA Food Code both require that prepared and ready-to-eat foods stored for more than 24 hours be clearly marked with the date of preparation or opening, and that such foods be discarded after a specified period. The FSD acknowledged during the interview that the undated food items should have been discarded, indicating a lapse in following established food storage protocols. No information about specific residents or their conditions was provided in the report.
Failure to Provide Timely Physical Therapy Evaluation for Knee Osteoarthritis
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services as required for a resident with bilateral primary osteoarthritis of the knees. The resident was referred by an orthopedic physician for a physical therapy (PT) evaluation and treatment to address knee pain and stiffness, with a specific order for PT to be conducted 2-3 times per week for 6-8 weeks. However, there was no evidence that a PT evaluation was completed following the physician's referral. The resident continued to experience pain that interfered with sleep and daily activities, as documented in the Minimum Data Set (MDS) assessment. Four months after the initial referral, a new request for a rehabilitation screen was made due to increased knee pain, and a subsequent physician's order again called for a PT evaluation. Despite these orders, the resident was only approached once for a PT evaluation, which was not completed due to the resident's temporary illness. Occupational therapy (OT) was conducted instead, but the OT evaluation did not assess knee pain or stiffness as specified in the PT order. There was no documentation that the resident was re-approached for PT after recovering from the illness. Interviews with rehabilitation staff confirmed that the PT evaluation was not completed as ordered and that the staff was unaware of the initial referral and order for PT services.
Failure to Disinfect Shared Blood Glucose Monitor Between Resident Uses
Penalty
Summary
Facility staff failed to adhere to infection prevention and control standards regarding the use of multi-resident medical equipment. During a medication administration observation, a nurse used a blood glucose monitor (BGM) to obtain a blood glucose level for a resident and then placed the BGM back into the medication cart with other clean equipment without cleaning or disinfecting it. The nurse acknowledged forgetting to clean the BGM after use, and both the unit manager and infection preventionist confirmed that facility policy requires all shared equipment, including BGMs, to be cleaned and disinfected between each resident use. The facility's policy on disinfecting shared resident equipment specifies that all such equipment must be cleaned and disinfected routinely, using methods appropriate for the equipment and type of contamination. Despite this policy, the observed nurse did not follow the required procedure after using the BGM, resulting in a failure to prevent potential transmission of communicable diseases and infections. This deficiency was identified for one resident out of a sample of 25 during the survey.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
