Blaire House Of Milford
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Massachusetts.
- Location
- 20 Claflin Street, Milford, Massachusetts 01757
- CMS Provider Number
- 225260
- Inspections on file
- 19
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Blaire House Of Milford during CMS and state inspections, most recent first.
Three residents experienced deficiencies in care, including failure to reconcile and administer critical medications upon admission, lack of required documentation for healthcare proxy activation, and failure to discontinue medications as ordered by a physician. These lapses resulted from incomplete admission processes, missing documentation, and failure to update electronic health records.
A resident with cognitive impairment and multiple diagnoses was struck in the face and side with a pillow by a roommate during an altercation. Staff separated the residents but did not recognize the incident as potential abuse, failed to notify law enforcement, and did not update the care plan or implement interventions to prevent recurrence. Facility policies for reporting and investigation were not followed, and required documentation was not completed.
A resident with moderate cognitive impairment and multiple diagnoses was struck with a pillow by their roommate, and although the incident was documented and facility leadership was notified, it was not reported to the state agency as required. The Administrator initially did not report the event, believing no physical contact had occurred, resulting in a 26-day delay before the incident was entered into the required reporting system.
A resident with chronic anemia and heart failure had critically low hemoglobin and hematocrit results that were not promptly reported to the provider, despite multiple attempts by the lab to notify staff. The provider was not informed until two days later, after the resident became lethargic, leading to a delayed hospital transfer and necessary interventions.
Surveyors found that staff did not consistently label or date food items in all kitchenettes, including opened thickened liquids, yogurt cups, soda, salad dressing, and other ready-to-eat foods. Multiple items were observed without required labels, dates, or were stored past expiration, in violation of facility policy and FDA Food Code. The Food Service Director confirmed that labeling and dating procedures were not always followed.
The facility failed to maintain accurate infection surveillance and proper hand hygiene practices. The IP used outdated McGeer criteria, resulting in incomplete and inaccurate documentation of HAIs for several residents. Staff did not consistently perform hand hygiene during meal service or assist residents in cleaning their hands before meals, and the facility lacked a policy addressing these practices. These deficiencies led to a failure in providing a safe and sanitary environment.
Two residents who were eligible for updated pneumococcal vaccines (PCV20 or PCV21) were not screened, educated, or offered these immunizations as required by current CDC guidance. The facility relied on outdated protocols, resulting in a lack of documentation and shared decision-making regarding the newer vaccines.
The facility failed to inform residents of their right to not sign a binding arbitration agreement upon admission. Despite adding options to accept or decline, the agreement's wording led to confusion, resulting in residents signing agreements they intended to decline.
The facility failed to address and resolve grievances from residents through the Resident Council over several months. Despite policies requiring prompt action, grievances such as delayed staff assistance, medication issues, and noise disturbances were repeatedly raised but remained unresolved. The Activity Director documented grievances, but responses were incomplete, and the former DON did not address issues in her department. Residents expressed frustration over unresolved grievances, and the Administrator and current DON acknowledged the need for a more effective process.
The facility failed to transcribe physician's orders for GDR of antipsychotic medications for residents, did not follow manufacturer's instructions for administering Metamucil, and neglected to obtain pathology results for a resident post-surgery. Additionally, a diabetic resident was self-administering blood sugar tests without a physician's order or assessment.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended across three units. Observations showed carts were left accessible in areas like nurses' stations and dining areas, contrary to the facility's policy. Interviews with nursing staff and the DON confirmed the expectation for carts to be locked when unattended.
A resident with a history of stroke and limited mobility was found to have their call light consistently out of reach, contrary to facility policy. Despite staff acknowledging the need for the call light to be accessible, it was repeatedly observed on the floor, highlighting a failure to accommodate the resident's needs.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident with an indwelling Foley catheter did not have a care plan, confirmed by staff interviews. Another resident with dementia also lacked a care plan for their catheter. Additionally, a resident self-administering blood sugar tests and with an implantable cardiac device had no care plans for these aspects of care, as confirmed by staff.
A resident was discharged without a complete recapitulation of their stay, including their course of illness and treatment. The discharge paperwork lacked essential information such as Admission Diagnosis and Summary of Course of Stay. Staff interviews revealed that each department was responsible for completing sections of the discharge paperwork, but the summary section was not completed. The DON confirmed this oversight.
A resident with a history of a brain tumor and epilepsy fell from a wheelchair and hit their head in the dining room. Contrary to the facility's Falls Policy, a dietary aide moved the resident back into the wheelchair before a nurse could assess them. The aide was unaware of the policy, and the Director of Nursing was not informed of the premature move. The resident was sent to the hospital and returned with no injuries.
A resident with an indwelling catheter was observed multiple times with the catheter drainage bag lying on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed that the bag should be hanging from the bed, highlighting a failure in infection control practices.
A facility failed to conduct timely AIMS assessments for a resident receiving Olanzapine, an antipsychotic medication, as part of their drug regimen. The AIMS assessment, crucial for monitoring tardive dyskinesia, was last completed in September 2023, contrary to the expected every six-month interval. The Director of Nursing confirmed the lapse, highlighting a deficiency in adhering to standards of practice for monitoring adverse effects of psychotropic medications.
A facility failed to implement proper contact precautions for a resident with MDRO and VRE infections. Despite physician's orders, an incorrect precaution sign was posted, leading to staff not wearing appropriate PPE. A nurse was observed without a gown while performing tasks requiring contact precautions. The DON confirmed the error and acknowledged the need for correct PPE use.
A facility failed to administer a pneumococcal vaccine to a resident despite obtaining consent, as per CDC guidelines and facility policy. The resident, with diabetes and dementia, consented to the vaccine, but there was no record of administration. The DON confirmed the oversight during an interview, highlighting a lapse in the facility's vaccination process.
A resident, eligible for an updated COVID-19 vaccine, did not receive the vaccination despite having signed consent. The DON confirmed that while consent was obtained, there was no documentation of the vaccine being administered in the MIIS.
The facility failed to complete and transmit MDS discharge assessments within the required timeframe for four residents. Despite the CMS RAI Manual's requirement for completion within 14 days post-discharge, assessments for these residents were not completed, as confirmed by an MDS nurse. The DON acknowledged the expectation for timely completion and submission, highlighting a lapse in adherence to submission timeframes.
The facility failed to accurately complete MDS assessments for four residents, leading to deficiencies in documenting their care. A resident with dementia and weakness had multiple falls, but only one was recorded in the MDS. Another resident's fall was not documented, and a third resident's hospice status was omitted. Additionally, a resident's fall with a major injury was not recorded. MDS Nurse #2 confirmed the inaccuracies, and the DON stated that MDS assessments should accurately reflect residents' status.
Failure to Meet Professional Standards in Medication Reconciliation, Documentation, and Order Implementation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident newly admitted with multiple complex diagnoses, including heart failure and dementia, the facility did not complete medication reconciliation or physician notification at the time of admission. The resident's family brought in topical antifungal medications and a list of home hospice medications, but many of these, including critical cardiac and dementia medications, were not ordered or administered. The admission checklist, which required reconciliation of medications and physician approval, was not completed by the admitting nurse, resulting in the omission of 17 medications from the resident's regimen. Another resident with severe cognitive impairment had a healthcare proxy (HCP) activated prior to admission, with the HCP making all medical decisions. Despite this, the required HCP invocation/activation form, which documents the physician's determination of incapacity, was not completed or present in the medical record. Interviews with facility staff and the physician confirmed that the form was missing and should have been completed at the time the HCP was activated. A third resident with dementia and heart failure had a physician's telephone order to discontinue two dementia medications. However, the DON did not discontinue these medications in the electronic health record, and the resident continued to receive them for several days after the discontinuation order. This failure to implement physician orders in a timely manner was confirmed through record review and staff interviews.
Failure to Implement Abuse Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse prevention policy following a resident-to-resident altercation involving a resident with a history of sciatica, Parkinsonism, and bipolar disorder, who was moderately cognitively impaired. The incident occurred when the resident's roommate rummaged through their belongings, leading to a verbal exchange and the roommate throwing a pillow that struck the resident in the face and left side. Staff intervened and separated the residents, but the event was not recognized or treated as potential abuse at the time. Despite facility policies requiring prompt reporting of suspected abuse to local law enforcement and the implementation of interventions to prevent future incidents, these steps were not taken. The nursing note documented the altercation but incorrectly stated that no physical contact was made, and there was no indication that law enforcement was notified or that any follow-up interventions were put in place. The resident's care plan was not updated to reflect the incident or to include measures to prevent recurrence. Interviews with staff, including the social worker, DON, and administrator, revealed a lack of understanding and misinterpretation of what constitutes physical contact and abuse. The administrator acknowledged being aware of the incident but did not implement the abuse protocol, and the nurse on duty did not complete an incident report or notify authorities. The required investigational forms were not completed, and the facility's abuse policy and procedures were not followed, resulting in a failure to protect the resident and ensure appropriate reporting and intervention.
Failure to Timely Report Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The facility failed to report a resident-to-resident altercation as potential abuse in accordance with its abuse prevention policy and state requirements. The incident involved a resident with moderate cognitive impairment and diagnoses including sciatica, Parkinsonism, and bipolar disorder, who was struck in the face and left flank area with a small pillow by their roommate. The event was documented in the nursing notes, and the Administrator, DON, NP, and the resident's POA were notified. However, the incident was not reported to the State Agency as required by the facility's policy and state regulations. The Administrator was aware of the incident and conducted an investigation but did not submit the required report to the Healthcare Facility Reporting System (HCFRS) at the time, as he initially believed no physical contact had occurred. It was later acknowledged by the Administrator that the incident should have been reported in accordance with the facility's investigation guidance and abuse policy. The failure to report was confirmed during interviews and review of the HCFRS, which showed the incident was not reported until 26 days after it occurred.
Failure to Timely Report and Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results were reported and acted upon in a timely manner for one resident with chronic iron deficiency anemia and congestive heart failure. On 4/1/25, the resident's CBC results showed a critically low hemoglobin (Hgb) level of 7.2 g/dL and a low hematocrit (Hct) of 21.9%. The laboratory made two attempts to notify the facility by phone on the same day, but there was no documentation that the provider was notified of these critical results on 4/1/25 or 4/2/25. Nursing progress notes did not indicate any provider notification until 4/3/25, when the resident was found to be very lethargic with decreased verbal responsiveness. At that time, a nurse practitioner evaluated the resident, reviewed the lab results, and ordered a transfer to the hospital. Interviews with nursing staff and providers confirmed that neither the nurse practitioner nor the covering physician was made aware of the critical lab results prior to 4/3/25. Both providers stated they would have taken action had they been notified earlier. The facility's policy required immediate provider notification and documentation for critical lab results, but this was not followed. The DON confirmed that the expectation was for critical results to be called in to the provider immediately. The failure to notify the provider resulted in a delay in the resident's evaluation and transfer to the hospital, where the resident ultimately received a blood transfusion and had anticoagulant medication stopped.
Failure to Label and Date Food Items in Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation by not properly labeling and dating food items in all three kitchenettes. Observations revealed multiple instances of opened and ready-to-eat food items, such as thickened liquids, yogurt cups, soda, salad dressing, garden salad, cake, and mandarin oranges, that were either undated, unlabeled, or stored beyond their expiration dates. The facility's own policies require that all resident food and beverage items stored in unit kitchenettes be clearly marked with the resident's name and the date the item was placed in storage, and that foods brought in from outside be labeled and dated by staff. Additionally, the FDA Food Code mandates that refrigerated, ready-to-eat, time/temperature control for safety foods held for more than 24 hours be clearly marked with a consume-by date. Despite posted reminders in each kitchenette, staff did not consistently label or date food items, as confirmed by the Food Service Director. Items such as thickened liquids were not dated upon opening, and several food items were found in refrigerators past their manufacturer’s expiration dates. The lack of proper labeling and dating of food items represents a failure to follow both facility policy and federal food safety standards, increasing the risk of foodborne illness among residents who are considered high risk.
Deficient Infection Surveillance and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by inaccurate and incomplete infection surveillance and inadequate hand hygiene practices. The Infection Preventionist (IP), who also served as the Director of Nursing (DON), was responsible for infection surveillance using the McGeer criteria. However, the facility's surveillance documentation for several residents was found to be incomplete or inaccurate, with missing or insufficient signs and symptoms to meet the criteria for healthcare-associated infections (HAIs). Additionally, the facility was using outdated McGeer criteria from 2013, despite a more recent revision being available, leading to further inaccuracies in infection reporting. Specific examples included residents being counted as having HAIs without sufficient documentation of required symptoms or diagnostic evidence, such as chest x-rays for pneumonia or detailed signs for skin infections. In some cases, surveillance forms were left blank or lacked critical information, and the IP acknowledged errors and lack of awareness regarding updated surveillance criteria. The facility's infection control report sheets and surveillance records did not align with the most current standards, resulting in misclassification and under-documentation of infections. Observations by surveyors revealed that staff did not consistently perform hand hygiene when entering or exiting resident rooms, between meal tray passes, or when assisting residents with meals. Residents were not offered or encouraged to clean their hands before meals, and staff used regular napkins instead of designated hand wipes, which were reportedly out of stock. Staff interviews confirmed that hand hygiene protocols were not being followed, and the facility lacked a policy specifically addressing hand hygiene during meal pass and meal assistance. These lapses contributed to an environment that did not meet infection prevention and control standards.
Failure to Screen, Educate, and Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility, educated about, and offered the recommended PCV20 or PCV21 pneumococcal vaccinations in accordance with current CDC guidance. Both residents had previously received PCV13 and PPSV23 vaccinations several years prior, making them eligible for the newer vaccines. However, their medical records did not indicate that they or their responsible parties were informed about or offered the PCV20 or PCV21 vaccines, nor was there documentation of shared decision-making regarding these immunizations. The facility's policy required informed consent, physician orders, education, and documentation for vaccine administration, but the process was not followed for these residents. During an interview, the Infection Preventionist acknowledged that the facility was using outdated guidance from 2015 and was unaware of the updated CDC recommendations to offer PCV20 or PCV21 to eligible residents. As a result, the necessary steps to assess, educate, and offer the vaccines were not completed for the two residents in question.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to fully inform all residents of their right to not sign a binding arbitration agreement upon admission. The facility's Resident and Facility Arbitration Agreement, last revised in February 2022, indicated that any legal disputes would be resolved exclusively by binding arbitration, and residents were waiving their right to a court trial. The agreement also stated that signing it was not a precondition for receiving services and could be rescinded within 30 days. However, during the entrance conference, the Administrator stated that every resident had signed the agreement, suggesting a lack of proper communication regarding the residents' rights to decline. Interviews with the Business Office Manager (BOM) revealed that the arbitration agreements were included in the admission packet and reviewed with residents or their representatives. In 2023, the facility began asking all residents to sign the agreement, adding handwritten options to accept or decline. Despite this, the Administrator and BOM admitted that the agreement was confusing, as it implied that signing indicated both understanding and agreement to enter into the contract. They provided copies of signed agreements, many of which had 'Declined' circled, yet were still signed, indicating a misunderstanding of the agreement's implications.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances brought forward by residents through the Resident Council from September 2023 to March 2024. The facility's policies require the Grievance Officer, either the Executive Director or the Director of Nursing (DON), to oversee the grievance process, ensuring grievances are tracked and resolved promptly. However, the review of Resident Council Minutes revealed multiple grievances, such as delayed staff assistance, medication issues, and noise disturbances, that were repeatedly raised by residents but remained unresolved. Interviews with the Activity Director, who coordinates Resident Council Meetings, indicated that grievances were documented and communicated to the relevant departments using Interdisciplinary Communication Forms. Despite this process, the Activity Director found incomplete and unsigned responses for grievances from the February 2024 meeting, and noted that the former DON did not address grievances related to her department. This lack of follow-up and resolution was confirmed by the Administrator and the current DON, who acknowledged the absence of documented responses in the grievance book. Residents expressed frustration during a surveyor-led Resident Group meeting, stating that their grievances were acknowledged but not resolved, with some issues persisting over several months. The Administrator and DON admitted the need for a more effective process to ensure grievances are addressed and resolved in a timely manner, ideally before the next Resident Council Meeting.
Failure to Transcribe Orders and Follow Protocols
Penalty
Summary
The facility failed to transcribe and implement physician's orders for gradual dose reduction (GDR) of antipsychotic medications for several residents. For one resident with severe cognitive deficits, the physician agreed with a psychiatric nurse practitioner's recommendation to decrease the dosage of Haloperidol, but the order was not transcribed into the resident's record. Similarly, another resident with bipolar disorder and dementia was supposed to have their Olanzapine dosage reduced, but the order was not transcribed, and a re-evaluation of the medication was not conducted as required. Additionally, the facility did not adhere to the manufacturer's instructions for administering Metamucil to a resident with hemiplegia. The nurse administered the medication with only 5 ounces of water instead of the recommended 8 ounces. This deviation from the manufacturer's guidelines was acknowledged by the nurse, who cited the lack of appropriate cup sizes as the reason for the error. The facility also failed to follow up on pathology results for a resident who underwent surgical intervention for osteomyelitis. Despite a physician's order to obtain the pathology results to determine the need for further antibiotic treatment, there was no documentation of follow-up. Furthermore, a resident with diabetes was self-administering finger stick blood sugar tests without a physician's order or assessment of their ability to do so, which was acknowledged by the Director of Nursing.
Medication and Treatment Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely as required by their policy. Specifically, medication and treatment carts were observed to be unlocked and unattended on multiple occasions across three different units. These observations were made by surveyors on various dates, with carts being left unlocked in areas accessible to residents, such as in front of nurses' stations and along walls between nurses' stations and dining areas. The facility's policy mandates that all medications and biologicals should be securely stored in locked cabinets or carts, which was not adhered to in these instances. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expectation was for all medication and treatment carts to be locked when unattended. Nurse #4 and Nurse #3 acknowledged that the carts should have been locked when not supervised. The DON reiterated the facility's policy that all carts must be locked when not in use, highlighting a clear deviation from the established procedures. This deficiency was identified through a combination of direct observation, staff interviews, and a review of the facility's storage policy.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a violation of their policy on answering call lights. The resident in question was admitted with a history of cerebral infarction, hemiplegia affecting the right side, and aphasia, making them dependent on staff for self-care and mobility. Observations by the surveyor on multiple occasions revealed that the call light was consistently out of reach, either on the floor or clipped to the mattress in a manner that left it inaccessible to the resident. Interviews with staff, including a CNA and nurses, confirmed that the resident's call light should have been within reach at all times. Despite this, the call light was repeatedly found on the floor, and staff acknowledged the oversight. The Director of Nurses also stated that the expectation was for call lights to be accessible at all times, indicating a lapse in adherence to facility policy and staff awareness regarding the resident's needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their individual medical needs. Resident #14, who was admitted with diagnoses including hypertensive urgency and urinary retention, had an indwelling Foley catheter inserted but did not have a corresponding care plan developed. This oversight was confirmed during interviews with Nurse #5 and the Director of Nursing (DON), who acknowledged the absence of a care plan for the catheter, despite the facility's policy requiring one. Similarly, Resident #22, admitted with dementia, also had an indwelling Foley catheter inserted without a care plan being developed. The lack of a care plan was noted during interviews with Nurse #4 and Nurse #3, who confirmed that the care plan should have been updated to reflect the change in the resident's care needs. The DON reiterated the expectation for a care plan to be in place for residents with indwelling catheters, which was not met in this case. Resident #51, with diagnoses including atrial fibrillation and diabetes mellitus type 2, was found to be self-administering finger stick blood sugar testing and had an implantable cardiac device, yet no comprehensive care plans were developed for these aspects of care. Interviews with Nurse #2 and the DON revealed that the facility failed to create care plans for the resident's self-administration of blood sugar testing and the use of the implantable cardiac device, despite the facility's policy requiring care plans to reflect all aspects of a resident's care needs.
Incomplete Discharge Documentation
Penalty
Summary
The facility failed to document the recapitulation of a resident's stay, including their course of illness and treatment, at the time of a planned discharge. The resident was admitted with a partial amputation of the left great toe and discharged home at the end of January 2024. Upon review, the discharge paperwork, specifically the Discharge Plan, was found incomplete, with sections such as Admission Diagnosis, Summary of Course of Stay, Final Diagnosis, and other observations left blank. Interviews with staff revealed that each department was responsible for completing a section of the discharge paperwork, but the summary section was not completed as required. The Director of Nurses confirmed that the summary section should have been filled out, indicating a lapse in the discharge documentation process.
Failure to Follow Falls Policy After Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its Falls Policy & Procedure by not ensuring that a resident who sustained an unwitnessed fall with a head strike was assessed by a nurse before being moved. The incident involved a resident with a history of a malignant brain tumor and epilepsy, who was unable to complete a mental status assessment and had severely impaired cognitive skills. On the day of the incident, the resident fell from a wheelchair in the dining room and hit their forehead on the floor. Despite the facility's policy to leave the resident as found until a nurse could assess them, a dietary aide moved the resident back into the wheelchair before a nurse's assessment. Interviews revealed that the dietary aide, unaware of the policy, moved the resident after hearing them call for help and finding no staff nearby. The Director of Nursing was not aware of the resident being moved before a nurse's assessment. The incident report and staff statements confirmed that the resident was moved before being assessed, which was against the facility's policy. The resident was later sent to the hospital for evaluation and returned with no injuries from the fall.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder to drain urine. The deficiency was identified through observations, interviews, and record reviews. The resident, who was admitted with conditions including hypertensive urgency, cognitive communication deficit, and urinary retention, had a Foley catheter inserted in April 2024. The facility's policy and CDC guidelines specify that catheter drainage bags should not rest on the floor to prevent infections. However, on multiple occasions, the surveyor observed the resident's catheter drainage bag lying on the floor, sometimes in a privacy bag and sometimes not. Interviews with facility staff, including a CNA and a nurse, confirmed that the catheter drainage bags should be hanging from the bed and not placed on the floor. The Director of Nursing also stated that the expectation is for catheter drainage bags to be kept in a privacy bag and off the floor. Despite these guidelines and expectations, the facility did not adhere to proper infection control practices, as evidenced by the repeated observations of the catheter bag on the floor.
Failure to Conduct Timely AIMS Assessment for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications by not completing an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner. The AIMS assessment is a clinical tool used to monitor for tardive dyskinesia, a condition characterized by abnormal involuntary movements, and should be conducted every three to six months according to the National Library of Medicine. However, the facility's policy on antipsychotic medication use did not specify the intervals for conducting AIMS assessments. The resident in question was admitted with diagnoses of bipolar disorder and dementia with agitation and was receiving regular doses of the antipsychotic medication Olanzapine. The resident's records indicated that the last AIMS assessment was completed in September 2023, and subsequent assessments were not conducted every six months as expected. Interviews with the Director of Nursing confirmed that the psychiatric practitioner was expected to complete the AIMS assessment every six months, but this was not done for the resident. This oversight resulted in a failure to adhere to standards of practice for monitoring the adverse effects of psychotropic medications, specifically the development of tardive dyskinesia.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident diagnosed with sepsis and infection with Multi-Drug Resistant Organisms (MDRO). The resident was admitted with physician's orders for contact precautions due to MDRO and Vancomycin Resistant Enterococcus (VRE) infections. However, the facility did not implement these precautions correctly. Instead of a contact precaution sign, an enhanced barrier precaution sign was posted on the resident's door, which led to improper use of personal protective equipment (PPE) by the staff. During observations, a nurse was seen in the resident's room without wearing a gown while performing tasks that required contact precautions, such as applying skin prep and repositioning the resident. The nurse incorrectly believed that a gown was only necessary when dealing directly with the wound, despite the posted sign indicating otherwise. The Director of Nurses confirmed that the wrong precaution sign was posted and acknowledged that staff should have adhered to contact precautions, including wearing a gown and gloves, as per the facility's policy for residents with MDROs.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer pneumococcal vaccinations to Resident #46 in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and the facility's own policy. Resident #46, who was admitted in January 2021 with diagnoses of diabetes mellitus and dementia, had consented to receive the pneumococcal vaccination on August 25, 2021. The facility's policy required that residents be assessed for eligibility and offered the vaccine series within thirty days of admission unless contraindicated or already completed. Despite the consent being obtained, there was no documented evidence that the vaccination was administered. The Director of Nurses (DON), who also served as the Infection Prevention Nurse, confirmed during an interview that Resident #46 was eligible for the pneumococcal vaccine any time after December 31, 2021, following the administration of the PCV 13 vaccine on December 31, 2020. However, the DON acknowledged that there was no record of the vaccine being administered, despite the consent being in place. This oversight indicates a failure in the facility's process to ensure that vaccinations are administered as per policy and CDC guidelines.
Failure to Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer COVID-19 vaccinations to a resident in accordance with CDC recommendations and facility policy. A resident, who was admitted in January 2024 and was of eligible age, had previously received COVID-19 vaccinations in 2021 and 2022. Despite having signed consent to receive an updated COVID-19 vaccination in January 2024, there was no documented evidence that the vaccine was administered. The Director of Nurses, who also served as the Infection Prevention Nurse, confirmed during an interview that while the consent was obtained, the vaccination was not recorded as administered in the Massachusetts Immunization Information System (MIIS).
Failure to Complete MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) discharge assessments were completed within the required timeframe for four residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a discharge assessment must be completed no later than 14 calendar days after the discharge date. However, the facility did not adhere to this requirement for Residents #5, #12, #11, and #59, as their discharge assessments were not completed and transmitted within the specified period. Resident #5 was discharged on February 28, 2024, Resident #12 on January 18, 2024, Resident #11 on December 19, 2023, and Resident #59 on November 21, 2023. Despite these discharge dates, the assessments for these residents were not completed, as confirmed by MDS Nurse #2 during a telephonic interview. The Director of Nurses (DON) acknowledged that the expectation was for MDS assessments to be completed and submitted as required, indicating a lapse in the facility's adherence to federal and state submission timeframes.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care. Resident #47, who was admitted with dementia and weakness, experienced multiple falls between January and April 2024, but the MDS assessment dated April 11, 2024, only recorded one fall since the previous assessment. Similarly, Resident #58, admitted with weakness and repeated falls, had a fall on April 4, 2024, which was not documented in the MDS assessment of the same date. MDS Nurse #2 confirmed that the MDS assessments for both residents did not accurately reflect their fall history. Additionally, Resident #22, admitted with dementia and weakness, was on hospice care since December 6, 2023, but this was not indicated in the MDS assessment dated March 7, 2024. Resident #46, who had dementia and multiple fractures, was hospitalized after a fall in February 2024 and returned with a rib fracture. However, the MDS assessment dated March 11, 2024, failed to document the fall with a major injury. MDS Nurse #2 acknowledged the inaccuracies in the MDS assessments, and the Director of Nurses stated that the expectation was for MDS assessments to accurately reflect the residents' status.
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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