Brandon Woods Of Dartmouth
Inspection history, citations, penalties and survey trends for this long-term care facility in South Dartmouth, Massachusetts.
- Location
- 567 Dartmouth Street, South Dartmouth, Massachusetts 02748
- CMS Provider Number
- 225233
- Inspections on file
- 23
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Brandon Woods Of Dartmouth during CMS and state inspections, most recent first.
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 who was dependent on staff for transfers and had multiple medical conditions sustained a severe leg laceration after scraping against exposed metal on a bed frame during a transfer. The injury occurred because the bed was missing a protective cap, and staff did not use a gait belt as required by facility policy. The incident was confirmed by staff interviews and facility records.
A resident with multiple comorbidities who required staff assistance for transfers was moved from a wheelchair to bed by two CNAs without the use of a gait belt, contrary to facility policy. During the transfer, the resident's knees buckled, and staff had to grab the waistband of the resident's pants, resulting in the resident's leg being injured by exposed metal on the bed frame. Both CNAs admitted to not using a gait belt despite being trained and aware of the policy.
A resident with complex medical conditions experienced a significant drop in oxygen saturation, requiring an increase in oxygen flow. The LPN documented the event and left a note in the physician's folder but did not directly notify the provider. Interviews with the physician, NP, unit manager, and DON confirmed they were not informed of the change, despite facility policy requiring immediate notification of such events.
During an outbreak of COVID-19, Influenza, and RSV, the facility failed to ensure staff adhered to PPE protocols. Staff were observed not wearing required PPE, such as N-95 masks and gowns, when entering isolation rooms. Hand hygiene was also neglected, and PPE was improperly handled, leading to potential contamination. The Infection Preventionist was new, and education on PPE use was insufficient.
The facility failed to implement an effective Antibiotic Stewardship Program, resulting in incomplete documentation and tracking of antibiotic use among residents. The facility's policy requires the collection of antibiotic usage data, but reviews of records for several months showed missing critical information. The DON and new IP acknowledged the deficiencies, with the DON admitting to not reviewing antibiotic use with McGeer criteria or engaging in necessary reviews with providers, leading to the program's ineffective implementation.
The facility failed to discard expired food items in a kitchenette, including crab meat, salami, and oranges, which were past their expiration dates. The Food Service Director acknowledged the oversight, and a dietary aide confirmed that expired food should have been removed, indicating a lapse in following the facility's policy on handling foods brought in from outside sources.
A facility failed to maintain accurate documentation for a resident with diabetes, as the MAR for February 2025 did not reflect blood sugar values and insulin dosages according to physician's orders. There were multiple instances of missing documentation due to incomplete entry of sliding scale orders in the system. Interviews revealed that the supporting documents tab was not checked, preventing proper documentation, and the DON confirmed the lack of a method to indicate blood sugar values or insulin amounts.
A resident consented to receive the Pneumococcal vaccine upon admission, but the facility failed to administer it in a timely manner. The resident had previously received PCV-13 and PPSV-23 vaccines outside the facility. Interviews revealed that the Infection Preventionist responsible for vaccine administration had left, causing a lapse in the process. The new IP and DON confirmed that the process for obtaining consents and administering vaccines was not completed for this resident.
The facility failed to transmit MDS assessments within the required 14 days for several residents. The assessments, completed by an LPN and signed by the RN MDS Coordinator, were not submitted to iQIES on time. Interviews confirmed the delay in submission.
The facility failed to ensure that MDS assessments for two residents were signed off by the RN MDS Coordinator, as required by RAI guidelines. An LPN completed and signed the assessments, but the necessary RN certification was missing. Interviews confirmed the oversight, with the current RN MDS Coordinator stating that all MDS assessments must be signed by an RN.
A resident with severe cognitive impairment and dysphagia was left unsupervised during a meal, contrary to their care plan, resulting in a choking incident that required the Heimlich Maneuver. Staff interviews confirmed the need for supervision, but no staff was present, leading to a significant lapse in care protocol adherence.
A resident with dysphagia and severe cognitive impairment was left unsupervised during a meal, leading to a choking incident. The resident was served a meal inconsistent with their dietary orders, containing whole meatballs instead of chopped food. Staff failed to check the meal tray for accuracy and did not provide the required supervision, resulting in the resident choking and requiring the Heimlich Maneuver.
A resident with dysphagia was served whole meatballs instead of chopped, as per their dietary needs, leading to a choking incident. The dietary aide called out the correct diet order, but the cook served the meal as a regular diet. The nursing staff failed to verify the meal tray against the resident's meal ticket, resulting in the resident choking and requiring the Heimlich Maneuver.
A resident at an LTC facility fell during a transfer when a mechanical lift sling strap became detached, leading to complaints of hip and knee pain. The facility's policy required a double-check of sling attachments, which was not performed by the staff involved in the transfer. The resident had a history of conditions increasing fall risk and was dependent on staff for transfers.
Two residents in a long-term care facility suffered injuries due to staff failing to follow care plans requiring two-person assistance for transfers and bed mobility. One resident fell and fractured their hip, while another sustained an ankle sprain during an improper transfer. Both CNAs involved admitted to not adhering to the care plans, which led to these incidents.
Two residents in an LTC facility suffered injuries due to inadequate staff assistance during transfers and bed mobility. One resident, requiring two staff members for bed mobility, was left unattended and fell, resulting in a fractured hip. Another resident, also needing two staff members for transfers, was moved by a single CNA, leading to an ankle sprain. These incidents highlight a failure to follow facility protocols for resident safety.
The facility did not have a full-time RN serving as the Director of Nursing (DON). The Interim DON, who was the Staff Development Coordinator, was an LPN and not an RN. The Administrator confirmed the absence of a full-time RN DON and stated that no waiver had been requested. The facility was interviewing candidates to fill the position.
A resident with a right elbow fracture required daily splint removal and dressing changes as recommended by an orthopedic PA. Nursing staff did not adhere to these instructions, resulting in a stage 4 pressure injury. The deficiency was linked to lapses in documentation and implementation of the care plan, as well as communication gaps among the nursing team and facility management.
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.
Resident Injury Due to Exposed Bed Frame and Improper Transfer Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, sustained a significant injury during a transfer. The resident, who was moderately cognitively impaired, required the assistance of two staff members for transfers. During a transfer from a wheelchair to bed, the resident's left leg scraped against an exposed piece of metal on the bed frame, resulting in a 10-centimeter laceration that required 10 sutures to close. The exposed metal was due to a missing protective plastic cap on the bed frame joint. Facility policy required that all equipment, including beds, be maintained in a safe and functional condition, with regular inspections to ensure safety. However, the bed in question was found to be several years old, and some of the protective plastic caps had come off, leaving sharp metal edges exposed. Staff interviews confirmed that the exposed metal was present at the time of the incident and that the injury was directly caused by contact with this hazard during the transfer process. Additionally, it was determined that the staff members involved in the transfer did not use a gait belt, which was required by facility policy to ensure resident safety during transfers. Both CNAs involved in the incident reported that the resident's leg caught on the exposed metal as they physically lifted the resident into bed, and neither had used a gait belt during the process. The lack of proper equipment use and the presence of an environmental hazard directly contributed to the resident's injury.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow facility policy and professional standards of practice during a transfer of a resident who was dependent on staff for mobility. The resident, who had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, required assistance for transfers and was assessed as moderately cognitively impaired and dependent on staff for transfers. On the evening of the incident, two CNAs assisted the resident in transferring from a wheelchair to bed without using a gait belt, despite being aware of and trained on the facility's policy requiring gait belt use for all assisted transfers. During the transfer, the resident's knees buckled, and the staff had to grab the waistband of the resident's pants to prevent a fall. As a result, the resident's left leg came into contact with an exposed piece of metal on the bed frame, causing a laceration. Both CNAs involved acknowledged in interviews that they did not use a gait belt during the transfer and were aware that this was against facility policy. Documentation confirmed that both CNAs had received training and signed acknowledgments regarding the gait belt policy and proper transfer techniques. The incident was witnessed and reported by nursing staff, and the Director of Nursing and Administrator confirmed that the facility's policy was not followed during the transfer. The failure to use a gait belt directly contributed to the resident's injury during the transfer process.
Failure to Notify Provider of Significant Change in Resident's Oxygen Status
Penalty
Summary
The facility failed to ensure prompt notification of a provider following a significant change in a resident's condition. According to the facility's policy, nurses are required to immediately notify the resident's physician and representative of any significant changes in the resident's medical, mental, or psychosocial status. In this case, a resident with multiple complex diagnoses, including chronic kidney disease, respiratory failure, and pulmonary edema, experienced a dangerously low oxygen saturation level of 84% while on oxygen therapy. Nurse #2 increased the resident's oxygen flow rate and documented the event in the medical record and physician's folder but did not directly notify the physician or nurse practitioner of the change in condition. Interviews with the physician, nurse practitioner, unit manager, and director of nursing confirmed that none were informed of the resident's hypoxic episode or the need for increased oxygen support. All staff interviewed stated that such a change in condition should have been reported immediately to the provider. Review of the medical record showed no documentation of provider notification regarding the resident's low oxygen saturation or the adjustment in oxygen therapy, constituting a failure to follow facility policy and ensure timely provider awareness of a significant clinical change.
Inadequate PPE Use During Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during an outbreak of COVID-19, Influenza, and Respiratory Syncytial Virus (RSV). The deficiency was observed across three units where staff did not adhere to the required use of personal protective equipment (PPE) as per the facility's policies and guidelines. The facility's policies required the use of full PPE, including N-95 respirators, eye protection, gloves, and gowns for residents on isolation precautions. However, multiple staff members were observed not wearing the necessary PPE, such as goggles or face shields, while on the units. Specific instances of non-compliance included staff members entering rooms with isolation precaution signs without donning the required PPE, such as gowns and N-95 masks. For example, a Certified Nursing Assistant (CNA) entered a resident's room wearing only gloves, a surgical mask, and goggles, failing to wear a gown as required. Additionally, the CNA did not perform hand hygiene after removing gloves and before entering another room. Another CNA was observed entering a room with an N-95 mask improperly fitted, with one strap dangling, and later contaminating clean PPE by dropping it on the floor and placing it back in the holder. Further observations revealed that staff members, including housekeeping and maintenance personnel, did not perform hand hygiene or change their PPE after exiting isolation rooms. Some staff members were unaware of the requirement to clean or change eye protection upon exiting isolation rooms. The Infection Preventionist, who was new to the role, indicated that education on PPE use was provided by someone else at the start of the outbreak. The Director of Nursing (DON) and Administrator acknowledged the need for further education to ensure proper PPE use across all departments.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required, which led to incomplete documentation and tracking of antibiotic use among residents. The facility's policy mandates the collection and documentation of antibiotic usage and outcome data using a facility-approved surveillance tracking form. However, a review of the monthly antibiotic surveillance tracking records for November 2024, December 2024, and January 2025 revealed significant gaps in documentation. Many residents' records lacked critical information such as culture dates, sites of infection, and results, despite all residents being started on antibiotics. This incomplete documentation indicates a failure to properly track and evaluate antibiotic prescribing patterns, as outlined in the facility's policy. During an interview, the Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged the deficiencies in the antibiotic surveillance tracking records. The IP, who was new to the position and still in training, had not completed any line listings. The DON admitted to not reviewing antibiotic use with McGeer criteria to determine if illnesses met the criteria for infections and acknowledged that the line listings were incomplete and incorrect. Furthermore, the DON had not engaged in reviewing antibiotic justification for use or improvement of prescribing practices with providers, as required by the facility's antibiotic stewardship policy. This lack of adherence to the policy and incomplete documentation contributed to the facility's failure to effectively implement the Antibiotic Stewardship Program.
Failure to Discard Expired Food in Kitchenette
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to foodborne illness among residents. During a survey, it was observed that the facility did not discard food items that were past the manufacturer's expiration and use-by dates in one of the kitchenettes. Specifically, a resealable plastic bag of crab classic meat, a resealable plastic bag of salami, and a bag of Halos oranges were found in the refrigerator with expiration dates that had already passed. These items were identified by the Food Service Director (FSD) as being brought in from an outside source. Interviews conducted during the survey revealed that the FSD acknowledged the presence of expired food in the residents' refrigerator and stated that such items should have been discarded by the dietary aides. The FSD also noted that there should have been a guide for foods brought in by resident families and friends attached to the kitchenette's refrigerator door, but it was missing. Additionally, a dietary aide confirmed that expired food should have been removed from the refrigerator, indicating a lapse in following the facility's policy on handling foods brought in from outside sources.
Failure to Document Blood Sugar and Insulin Administration
Penalty
Summary
The facility failed to maintain accurate documentation for a resident with diabetes mellitus, specifically in the Medication Administration Records (MAR) for February 2025. The MAR did not accurately reflect blood sugar values and the dosage of insulin administered according to the physician's orders. The resident was prescribed Insulin Glargine and Insulin Lispro with specific instructions for administration based on blood glucose levels. However, there were 23 occasions where blood sugar values were not documented and 24 occasions where the insulin dosage was not recorded, as evidenced by blank boxes in the MAR. During interviews, it was revealed that the sliding scale order for insulin administration was not fully entered into the system, leading to incomplete documentation. Nurse #2 acknowledged that the supporting documents tab was not checked off, which prevented the documentation of blood sugar values and insulin dosages. The Director of Nurses confirmed that there was no way to indicate the blood sugar value or the amount of insulin administered, and stated that the expectation was for nurses to document these details on the MAR and follow up with the physician if necessary.
Failure to Administer Pneumococcal Vaccine in a Timely Manner
Penalty
Summary
The facility failed to provide the Pneumococcal immunization in a timely manner for a resident who had consented to receive it. The resident, who was admitted to the facility in February 2025, had previously received the Pneumococcal PCV-13 and PPSV-23 vaccines outside of the facility. Despite consenting to the Pneumococcal vaccine upon admission, the medical record did not indicate that the vaccine had been administered. This oversight was identified during a review of the resident's immunization record. Interviews with facility staff revealed a breakdown in the process for administering vaccines. The Infection Preventionist (IP), who was responsible for obtaining physician orders and administering vaccines, had recently left the position, leading to uncertainty about who would administer vaccines. The Director of Nursing (DON) and the new IP confirmed that the floor nurses were responsible for reviewing vaccine risks and benefits with residents and obtaining consents, which were then supposed to be provided to the IP for follow-up. However, the process was not completed for this resident, resulting in the failure to administer the Pneumococcal PCV-20 vaccine as qualified.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required 14 days after completion for seven residents. The MDS assessments for these residents, which included significant change, discharge, and death assessments, were completed and signed by either the RN Assessment Coordinator or an LPN. However, the iQIES submission data indicated that these assessments were not transmitted and accepted within the required timeframe. Interviews with the MDS Nurse and the RN MDS Coordinator revealed that the assessments for the residents were not submitted on time. The MDS Nurse, an LPN, stated that she completes the assessments, which are then signed off by the RN MDS Coordinator before submission. The RN MDS Coordinator, who was not in the role at the time of the deficiency, confirmed that the assessments should have been submitted within 14 days of completion but were late.
Failure to Ensure RN Sign-Off on MDS Assessments
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was signed off by the Registered Nurse (RN) MDS Coordinator as required by the Resident Assessment Instrument (RAI) guidelines. Specifically, the MDS assessments for two residents, who were admitted and later expired in the facility, were completed and signed by an LPN instead of the RN MDS Coordinator. The facility's policy mandates that the RN MDS Coordinator is responsible for certifying the completion of resident assessments, which was not adhered to in these cases. During interviews, the LPN responsible for completing the MDS assessments acknowledged that the assessments for the two residents were not signed by the RN Coordinator, as they should have been. The RN MDS Coordinator, who was not in the role at the time of these assessments, confirmed that all MDS assessments must be signed by an RN. The previous RN MDS Coordinator was responsible for signing off on the RN Attestation for all MDS assessments, but this was not done for the assessments in question.
Failure to Supervise Resident During Meals Leads to Choking Incident
Penalty
Summary
The facility failed to consistently implement and follow the care plan interventions for a resident with severe cognitive impairment and dysphagia, who required continual supervision during meals. On the specified date, the resident was left alone in their room with a lunch tray, contrary to the care plan that mandated staff supervision during meals. As a result, the resident choked on their food and required the Heimlich Maneuver to dislodge a piece of meatball from their throat. The facility's policy on comprehensive care planning emphasizes the development of individualized care plans that include measurable objectives and timetables to meet residents' needs. Despite this, the care plan for the resident, which was reviewed and renewed with their November 2024 MDS, was not adhered to, leading to the incident. Interviews with staff members, including CNAs and the Director of Nursing, confirmed that the resident required supervision while eating, yet no staff member was present at the time of the incident. The Director of Nursing and the Administrator acknowledged that the staff did not follow the resident's care plan, and the Administrator's investigation could not determine which staff member left the resident unassisted. The failure to provide the necessary supervision as outlined in the care plan directly contributed to the resident's choking incident, highlighting a significant lapse in the facility's adherence to care protocols.
Failure to Supervise Resident with Dysphagia Leads to Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision and ensure the correct diet for a resident with dysphagia, leading to a choking incident. The resident, who had severe cognitive impairment and required a chopped diet with continual supervision during meals, was left unsupervised while eating in their room. The meal served was inconsistent with the resident's dietary orders, containing whole meatballs instead of chopped food, which resulted in the resident choking and requiring the Heimlich Maneuver. The facility's policies on assisting residents with in-room meals and food and nutrition services were not followed. Staff failed to check the meal tray for accuracy against the resident's meal ticket, which specified a chopped diet. Additionally, the resident did not receive the necessary supervision during the meal, as no staff member was present in the room to assist or monitor the resident while eating. Interviews with staff revealed that the responsibility for checking meal trays and providing supervision was not adequately fulfilled. The nurse on duty admitted to not checking the meal trays before they were served, and the CNAs confirmed that the resident was left alone during the meal. The incident highlighted a breakdown in communication and adherence to established protocols, resulting in a serious safety lapse for the resident.
Failure to Provide Correct Meal Texture Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that meals prepared and served to a resident with dysphagia met the individual's dietary needs and physician's orders. The resident, who had a history of difficulty swallowing, was supposed to receive a house regular diet with chopped food. However, during a lunch service, the dietary staff did not provide the correct texture of food, resulting in the resident being served whole Swedish meatballs instead of chopped ones. This oversight led to the resident choking on the food and requiring the Heimlich Maneuver to dislodge it. The incident occurred when a dietary aide called out the resident's diet order as house chopped, but the cook, who was under the impression that the meal could be served as a regular diet, did not chop the meatballs. The dietary aide questioned the appropriateness of the meal but was assured by the cook that it was acceptable to serve it as is. Consequently, the meal was placed on the resident's tray without further verification against the meal ticket, which clearly indicated a preference for chopped meals. Additionally, the nursing staff did not check the meal tray against the resident's meal ticket before it was served. Nurse #1, who was on duty at the time, was unaware that it was her responsibility to verify the accuracy of meal trays. This lack of verification and communication among the dietary and nursing staff contributed to the resident receiving an incorrect meal, leading to the choking incident.
Failure to Ensure Safe Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who required the use of a mechanical lift with the assistance of two staff members for transfers. On October 2, 2024, during a transfer from a chair to a bed, one of the straps of the mechanical lift sling became detached, causing the resident to slide out of the sling and fall to the floor. The resident immediately complained of pain in the left hip and knee. The facility's policy on using mechanical lifts, revised in July 2017, outlines the necessary steps to ensure safety, including double-checking the security of sling attachments before lifting a resident. Resident #1, admitted to the facility in November 2020, had a history of atrial fibrillation, muscle weakness, difficulty in walking, hypothyroidism, hypertension, and heart failure. The resident was assessed as being at an increased risk for falls and was dependent on staff for all activities of daily living, including transfers. On the day of the incident, Nurse #1, CNA #1, and Hospice Aide #1 were involved in the transfer process. Despite visually checking the sling straps, they failed to perform a physical double-check to ensure the straps were securely attached to the lift. Interviews with the staff involved revealed that while they visually confirmed the sling straps were attached, they did not perform the required double-check by pulling down on the straps to ensure security. The facility's internal investigation and subsequent interviews with the staff and the administrator indicated that the most plausible reason for the incident was the lower left hook strap not being fully secured to the lift. The administrator acknowledged that the staff did not follow the facility's policy of double-checking the sling attachments, which contributed to the accident.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in the care plans for two residents who required the physical assistance of two staff members for transfers and bed mobility. In the first incident, a certified nurse aide (CNA) provided care to a resident without assistance, leaving the resident unattended on their side in bed. The resident subsequently fell and was diagnosed with a fractured left hip, necessitating surgical intervention. In the second incident, another CNA transferred a resident from a wheelchair to bed without the required assistance of a second staff member. During the transfer, the resident complained of left ankle pain and was later diagnosed with a second or third-degree lateral ankle sprain, requiring a brace for comfort. Both CNAs admitted to not following the residents' care plans, which specified the need for two staff members during such activities. The facility's policies, including the Care Plans Policy and Resident ADL Guide/Kardex, were not adhered to by the staff involved. These policies require that care plans be individualized, comprehensive, and regularly updated to reflect the residents' needs and conditions. The failure to follow these protocols resulted in injuries to the residents, highlighting a significant lapse in the implementation of care plans and staff adherence to established procedures.
Failure to Provide Adequate Staff Assistance Leads to Resident Injuries
Penalty
Summary
The facility failed to provide the required level of staff assistance for two residents, leading to accidents and injuries. Resident #2, who was admitted in April 2023 with multiple diagnoses including cerebral infarction and dementia, required the physical assistance of two staff members for bed mobility. On 08/05/24, CNA #2 provided care to Resident #2 without assistance, leaving the resident unattended on their side in bed. This resulted in Resident #2 falling out of bed and sustaining a fractured left hip, which required surgical intervention. Similarly, Resident #1, admitted in August 2023 with conditions such as sepsis and muscle weakness, was also dependent on two staff members for transfers. On 08/03/24, CNA #1 transferred Resident #1 from a wheelchair to bed without assistance, leading to the resident twisting their left ankle. The resident later complained of pain, and an orthopedic evaluation revealed a second or third-degree lateral ankle sprain, necessitating the use of a brace. Both incidents highlight the facility's failure to adhere to its own policies regarding the required staff assistance for residents with specific mobility needs. The lack of adherence to these protocols resulted in significant injuries to the residents, demonstrating a critical lapse in ensuring a safe environment free from accident hazards.
Deficiency in RN Director of Nursing Position
Penalty
Summary
The facility failed to ensure that there was a Registered Nurse (RN) serving as the Director of Nurses (DON) on a full-time basis. During the entrance conference, the Interim DON, who was the Staff Development Coordinator, stated that she had been serving in the interim role since 8/11/24 and was a Licensed Practical Nurse (LPN), not an RN. The Key Personnel List provided to the surveyor did not include information for the Director of Nursing position, indicating a vacancy. In an interview, the Administrator confirmed that the facility did not have a full-time RN DON and acknowledged that the Interim DON was an LPN. The Administrator also mentioned that no waiver had been requested for the DON position and that the facility was in the process of interviewing candidates to fill the role.
Failure to Follow Orthopedic Care Plan Leads to Pressure Injury
Penalty
Summary
The deficiency identified in the report pertains to the failure of the nursing facility to adhere to professional standards of care for a resident (Resident #1) who required a splint for a right elbow fracture. Despite recommendations from the orthopedic Physician Assistant (PA) to remove the splint and change the dressing daily until healed, these instructions were not followed by the nursing staff. As a result, Resident #1 developed a pressure injury to the right elbow, which was discovered during a follow-up appointment. The report highlights that there was a lack of documentation and implementation of the recommended care plan, leading to the worsening of the resident's condition. The report details the sequence of events, including Resident #1's admission diagnoses, assessments indicating a high risk for pressure injuries, and the orthopedic recommendations for care. It outlines instances where nursing documentation did not reflect the required actions, such as removing the splint and changing the dressing daily. Interviews with the involved nurses revealed oversights in reviewing and implementing the orthopedic consultation recommendations, ultimately resulting in the development of a stage 4 pressure injury on Resident #1's right elbow. The report also includes statements from the Orthopedic PA, nurses, Unit Manager, and Administrator, shedding light on the communication gaps and responsibilities within the facility regarding consultation reviews and implementation of care plans. The deficiency was attributed to the failure of nursing staff to follow through on the orthopedic recommendations, leading to the adverse outcome for Resident #1. The detailed documentation and interviews provided a clear picture of the events that transpired, highlighting the need for improved processes and oversight to prevent similar deficiencies in the future.
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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