Brandon Woods Of New Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bedford, Massachusetts.
- Location
- 397 County Street, New Bedford, Massachusetts 02740
- CMS Provider Number
- 225264
- Inspections on file
- 21
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Brandon Woods Of New Bedford during CMS and state inspections, most recent first.
A resident with intact cognition and dependent care needs alleged rough treatment by a CNA during pericare. The allegation was reported by the resident's health care agent to the Unit Manager, but the Executive Director was not notified until the following day, contrary to facility policy requiring immediate reporting of abuse allegations.
A cognitively impaired resident was subjected to profane language by a CNA during care, and although the incident was reported to a nurse, the nurse failed to immediately notify facility administration as required by policy. The delay in reporting meant that the administration was not made aware of the alleged abuse until the following day.
A resident with severe cognitive impairment and a history of aggression and sexually inappropriate behaviors was not adequately managed by the facility, leading to multiple incidents of abuse and neglect. The facility failed to develop a comprehensive care plan or implement protective measures, and staff did not report incidents as required. Despite awareness of the resident's behaviors, the administration did not take effective action to ensure the safety of other residents.
A resident with conduct disorder, dementia, and major depression exhibited severe cognitive impairment and engaged in aggressive and sexually inappropriate behaviors. The facility failed to develop and implement a comprehensive care plan to address these behaviors, resulting in multiple incidents of the resident wandering into other residents' rooms, engaging in inappropriate behavior, and being involved in physical altercations. Staff were aware of these behaviors but did not report them or implement protective measures, leading to a deficiency in care.
A resident with severe cognitive impairment and a history of aggressive and sexually inappropriate behaviors was not adequately managed by the facility. Despite multiple incidents of abuse and neglect, staff lacked the necessary competencies and skills to address the resident's needs, and no effective interventions or care plans were developed. The facility's policies on abuse prevention and behavior management were not effectively implemented, and staff training was insufficient.
A resident with severe cognitive impairment and a history of aggressive and sexually inappropriate behaviors was involved in multiple incidents of abuse towards others. The facility failed to report these incidents to the DON, Administrator, state agency, or law enforcement, and did not implement protective measures. Additionally, only a small percentage of staff completed mandatory abuse prevention training, contributing to the failure to address the incidents. The lack of coordination with the QAPI program further exacerbated the issue, compromising resident safety.
A facility failed to report multiple incidents of abuse and neglect involving a resident with severe cognitive impairment and behavioral disturbances. The resident was involved in five documented incidents of physical and sexual abuse, as well as neglect, which were not reported to the state agency or law enforcement as required. Staff interviews revealed a lack of reporting and intervention, and the facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate and address five allegations of abuse and neglect involving a resident with severe cognitive impairment and behavioral disturbances. The resident exhibited aggressive and sexually inappropriate behaviors, including physical abuse and sexual harassment, which were documented but not investigated. Staff interviews revealed these behaviors were considered baseline, and no protective measures were implemented, leading to a significant deficiency in handling abuse and neglect allegations.
The facility failed to develop and implement comprehensive care plans for residents with behavioral and physical needs. A resident with severe cognitive impairment and aggressive behaviors lacked a care plan addressing these issues, despite multiple incidents. Another resident with hypersexual behaviors also lacked a care plan, even after hospitalizations. Additionally, residents with specific physical needs, such as fall prevention and appropriate seating, did not have updated care plans. The facility's failure to update care plans was acknowledged by staff, indicating a systemic issue.
A resident at high risk for pressure ulcers did not receive appropriate preventative care upon admission, leading to the development of a Stage III pressure ulcer on the right heel. Despite recommendations from a Wound Care Specialist, the facility failed to implement timely interventions, resulting in the ulcer becoming infected with MRSA. The lack of a care plan and preventative measures contributed to the resident's condition worsening.
A facility failed to address the behavioral needs of a resident with a history of aggression and inappropriate sexual behavior, leading to an unsafe environment for other residents. Despite multiple incidents, the facility lacked evidence of interventions or discussions by the interdisciplinary team. Staff training on abuse and behavior was insufficient, and the QAPI process did not analyze incidents to determine necessary changes.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical information about resident needs and staff competencies. The assessment, last updated in December 2023, lacked input from key individuals and did not include a Hazard Vulnerability Analysis. The Administrator and DON acknowledged the deficiencies during interviews.
The facility failed to ensure mandatory effective communications training for direct care staff, with only 48% completion. The Facility Assessment did not indicate the requirement for such training, and the Administrator and DON could not provide training content. The SDC acknowledged the low compliance rate as unacceptable.
The facility failed to ensure all staff received training on Resident's Rights, with only 10% of staff completing the required training. The policy mandates training during orientation and ongoing, but records showed only 16 out of 163 staff members completed it. The Administrator could not provide training content, and the Staff Development Coordinator acknowledged the low compliance rate as unacceptable.
The facility failed to ensure all staff were trained in abuse prevention and reporting protocols, with only 30% of staff completing the required training. Despite having a policy for comprehensive training, the facility's records showed inadequate compliance, and the Staff Development Coordinator acknowledged the low completion rate as unacceptable.
The facility failed to adequately train staff on the Quality Assurance Performance Improvement (QAPI) program, with only 17 out of 163 staff members completing the training in the past year, resulting in a 10% completion rate. The Administrator could not provide training content, and the Staff Development Coordinator acknowledged the low compliance as unacceptable.
The facility did not ensure all staff were trained on infection prevention and control standards, with only 32% of staff completing the required training. The Administrator could not provide class content, and the Staff Development Coordinator acknowledged the low completion rate as unacceptable.
The facility failed to provide staff training on ethics standards, policies, and procedures, as no current staff completed the required Corporate Compliance training in the past year. The Administrator could not provide class content, and the Staff Development Coordinator was unaware of the training requirement.
The facility failed to maintain records of CNA training, as required, with no less than 12 hours of mandatory training per year. The Administrator and DON could not provide proof of training content or hours, and the SDC admitted to not tracking CNA training hours, relying on an electronic system without access to in-person in-services. The facility was unable to provide documentation for five CNAs, acknowledging non-compliance with training requirements.
The facility failed to provide required behavioral health training to staff, with only 15% completing the necessary courses. The Facility Assessment did not indicate the need for such training, and the Administrator was unsure if a training plan existed. The Staff Development Coordinator acknowledged the low compliance rate as unacceptable.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting significant health conditions. A resident with a Stage 3 pressure ulcer and dementia experienced significant weight loss, which was not reflected in the MDS. Another resident with dysphagia and dementia also had significant weight loss that was not documented. Additionally, a resident with bipolar disorder had a foot wound that was not recorded in the MDS, despite treatment within the look-back period.
The facility failed to rotate injection sites for a resident receiving IM antibiotics, risking improper medication absorption, and did not obtain a physician's order for another resident's hospital transfer following a change in wound condition. Staff interviews confirmed the lack of documentation and adherence to procedures.
A facility failed to ensure a physician signed and dated all orders for a resident with dementia, depression, and bipolar disorder. The resident's orders had not been signed since January 2024, and a binder with unsigned orders from February to October 2024 was found. The nurse confirmed the unsigned orders, and the DON was aware of the issue. The physician was unaware of the binder and only signed orders in the resident's chart.
The facility did not meet the requirement of having an RN on duty for at least eight consecutive hours daily, seven days a week, without a staffing waiver. The review of schedules showed that on weekends, the facility lacked RN coverage for the required hours. The Staff Scheduler and DON confirmed the deficiency, acknowledging the absence of an RN for the necessary hours.
The facility failed to act on pharmacist recommendations during monthly Medication Regimen Reviews for two residents. One resident was receiving Clonazepam without a stop date, which was not flagged by the pharmacist. Another resident's physician did not address recommendations for a gradual dose reduction of Seroquel, despite repeated suggestions. Both residents had significant cognitive impairments and were on psychotropic medications.
The facility failed to follow professional standards for food safety and sanitation, with surveyors observing undated and improperly stored thickened beverages across three kitchenettes. Additionally, staff were seen eating in a kitchenette designated for resident use, contrary to facility policy. The FSD and DON confirmed these practices were against expectations and guidelines.
The facility failed to maintain accurate medical records for four residents, with significant delays in documenting physician visits and missing Health Care Proxy Forms. Physicians admitted to delays in sending notes, and the Medical Records Clerk confirmed that notes were not always filed. This resulted in incomplete records, impacting the accuracy of resident care documentation.
The facility failed to ensure that the binding Arbitration Agreement was explained to two residents in a manner they could understand. Interviews revealed that the residents were unaware of the agreement's purpose and implications, and the Social Worker admitted to not reviewing the agreement with them. This lack of proper explanation and documentation led to the deficiency.
The facility's arbitration agreement failed to ensure the selection of a neutral arbitrator agreed upon by both parties, as required by federal regulations. The agreement referenced the AAA but did not clarify residents' rights regarding arbitrator selection. Interviews with residents revealed confusion and a lack of understanding about the arbitration process, with some residents unaware of the AAA and unable to navigate online resources for further information.
The facility failed to maintain a comprehensive QAPI program, neglecting to address ongoing concerns of physical and sexual abuse involving a resident with conduct disorder, major depression, and dementia. Despite the resident's history of aggression and inappropriate behaviors, the facility did not provide evidence of interventions or action plans to prevent further incidents. Interviews with the DON and Administrator revealed awareness of the issues, but the QAA committee did not address these concerns in their activities.
The facility failed to maintain an effective infection control program, with deficiencies in surveillance accuracy, water management planning, and hand hygiene practices. Surveillance line listings for residents were incomplete, lacking necessary data to meet infection criteria. The water management plan was outdated, and a nurse did not perform proper hand hygiene during a dressing change, compromising infection prevention efforts.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for several residents. Despite the facility's policy requiring monitoring and justification for antibiotic use, residents were prescribed antibiotics without meeting infection criteria, and there was no documentation justifying continued use. The IP and DON acknowledged the program was not followed, resulting in the deficiency.
A resident's right to smoke was not facilitated after being moved to a different floor in the facility, requiring staff assistance to access the smoking area. Despite the resident's expressed desire to smoke, staff did not assist, and there was no documented plan to address the resident's smoking needs. The resident felt their rights were violated, and staff interviews revealed a lack of communication and understanding regarding the resident's smoking rights.
A facility failed to allow a resident's representative to change the resident's MOLST form from DNR to Full Code, despite the representative's expressed wishes. The resident, lacking capacity to make healthcare decisions, was admitted with encephalopathy and cerebral infarction. The facility did not offer alternatives for amending the MOLST, such as mailing or delivering a new form, leaving the resident under a DNR status against the representative's wishes.
A resident with a history of UTIs was not administered an ordered antibiotic on time due to a holiday delay in pharmacy delivery and lack of access to the electronic medication dispensing system. The nurse failed to notify the physician about the delay, resulting in the resident missing the first dose. The facility's policy on notifying the physician of changes in condition was not followed.
A resident with dementia and behavioral issues was involuntarily secluded in their room by a stop sign banner intended to deter another resident. The banner, secured with Velcro, prevented the resident from leaving, despite multiple attempts. Staff interviews revealed the banner was not meant for this resident, and the Director of Nursing acknowledged its unnecessary use, as the other resident could be redirected.
A facility failed to document a resident's course of illness and treatment for a brief stay due to COPD. The resident signed out against medical advice, and the medical record lacked a recapitulation of the stay by the attending physician, despite the discharge occurring over 30 days prior. The Medical Records Coordinator confirmed the absence of necessary documentation, contrary to facility policy and state law.
A resident with a UTI did not receive the prescribed Rocephin IM injection due to a delay in accessing the medication from the electronic dispensing system. The pharmacy could not deliver the medication on time due to a holiday, and the nursing staff failed to notify the physician or access the medication from the system, resulting in a delay in treatment.
A resident with urinary issues did not receive a physician-ordered bladder scan due to facility staff's failure to perform and document the procedure. The resident, who was cognitively intact, reported urinary urgency and dribbling, but the scan was not conducted, and the physician was not informed. Interviews revealed staff were unaware of the resident's issues and the order, leading to a deficiency identified after surveyor intervention.
A resident with hypertension, diabetes, and dementia was not seen by a physician at the required intervals after admission, resulting in a 224-day gap between documented visits. The facility's policy mandates physician visits every 30 days for the first 90 days and at least every 60 days thereafter, with alternate visits by an NP. The DON acknowledged the oversight, noting the expectation for timely visits.
A facility failed to develop a comprehensive care plan for a resident with dementia, as required by their policy. Despite the resident's severely impaired cognitive skills and behavioral symptoms, no individualized interventions were documented. Interviews with staff confirmed the oversight, and an audit revealed that several residents were missing care plans.
The facility failed to manage psychotropic medications appropriately for two residents. One resident received a PRN anti-anxiety medication without a stop date or re-evaluation, while another resident did not have a gradual dose reduction attempted for an antipsychotic medication, nor was a clinical rationale documented for not doing so.
The facility failed to properly store medications and secure treatment carts. A nurse stored a resident's refused medications in a cart drawer, contrary to policy, and treatment carts were left unlocked and unattended, posing a risk to residents, including those with dementia. The DON confirmed these practices were unacceptable.
The facility did not update the nurse staffing information daily, as required, and failed to include the actual hours worked per shift for RNs, LPNs, and CNAs. The staffing document, last updated on 11/14/24, was observed on 11/18/24, missing necessary details. The Staff Scheduler, responsible for posting the information, admitted to not updating it and was instructed by the Administrator to exclude total hours worked, contrary to requirements.
The facility failed to issue necessary Medicare non-coverage notices to two residents, resulting in a compliance deficiency. One resident did not receive a NOMNC or SNF ABN when discharged from Medicare A before benefits were exhausted, while another resident did not receive a NOMNC after a voluntary discharge. The Business Office Manager confirmed the oversight was due to the responsible social worker's failure to provide the notices.
The facility failed to provide transfer/discharge notices to two residents and did not notify the Ombudsman of these transfers. One resident with severe cognitive impairment was transferred to the hospital after a fall, and another with a surgical wound complication did not receive a notice and chose to discharge home. The Ombudsman had not received any notices since August, and the facility's part-time social worker and DON were unaware of the lapses.
Failure to Timely Report Alleged Abuse to Executive Director
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy for a resident with intact cognition and a history of stroke who was dependent on staff for care. On 08/13/25, the resident's health care agent informed the Unit Manager that the resident had alleged that a CNA was rough during pericare on 08/10/25, even after being asked to stop. According to the facility's policy, all allegations of abuse must be reported immediately, but no later than two hours if abuse is involved, to the Executive Director and appropriate authorities. Despite this policy, the Unit Manager did not notify the Executive Director of the allegation until the following day, assuming the DON would inform him. The DON stated she was not aware of the allegation until it was discussed in a daily meeting on 08/14/25. The Executive Director confirmed he was not made aware until that meeting. This delay in reporting resulted in the facility not adhering to its own policy regarding the timely reporting of abuse allegations.
Failure to Immediately Report Alleged Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy regarding the immediate reporting of alleged resident abuse. Specifically, a Hospice CNA reported to Nurse #1 that while two CNAs were providing care to a cognitively impaired resident, one of the CNAs used profane language directed at the resident. Despite being informed of the allegation, Nurse #1 did not immediately notify her direct supervisor, the Executive Director, or the Director of Nursing as required by facility policy. Instead, the incident was not brought to the attention of facility administration until the following day, after the Unit Manager learned of the situation from one of the involved CNAs. The resident involved was cognitively impaired, with documented deficits in memory and decision-making skills. The failure to promptly report the allegation of verbal abuse delayed the facility's awareness and response to the incident, contrary to established procedures designed to protect residents from abuse, neglect, and mistreatment. The deficiency was identified through interviews and record reviews, which confirmed that the required chain of reporting was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to provide a safe environment free from abuse and neglect for a resident with severe cognitive impairment and a history of aggression and sexually inappropriate behaviors. The resident, who resided in the Dementia Special Care Unit, exhibited behaviors such as wandering into other residents' rooms, hitting other residents, and engaging in sexually inappropriate actions. Despite these behaviors, the facility did not develop a comprehensive care plan to prevent the resident from abusing others or being abused, nor did they implement effective protective measures. Interviews with staff revealed a lack of awareness and reporting of the resident's behaviors as potential abuse. Staff members, including nurses and unit managers, did not report incidents to the Director of Nursing or the Administrator, and no protective interventions were put in place. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed, as evidenced by the failure to report multiple incidents to the Department of Public Health and the lack of protective measures for other residents. The facility's administration was aware of the resident's behaviors and had previously considered transferring the resident to another facility for safety reasons. However, the resident's family opposed the transfer, and the facility continued to house the resident without implementing adequate interventions to manage the behaviors. The interdisciplinary team meetings did not result in new strategies to address the resident's actions, and staff turnover further complicated the situation, leading to a lack of continuity in care and supervision.
Failure to Address Behavioral Health Needs of Resident
Penalty
Summary
The facility failed to provide effective and appropriate treatment and services to ensure the highest practicable mental and psychological well-being for a resident with a known history of conduct disorder, dementia with behavioral disturbance, and major depression. The resident exhibited severe cognitive impairment and engaged in both physical and verbal aggressive behaviors, as well as wandering and sexually inappropriate actions. Despite these behaviors, the facility did not develop, implement, or update a comprehensive care plan to address the resident's behavioral needs, resulting in multiple incidents of the resident wandering into other residents' rooms, engaging in sexually inappropriate behavior, and being involved in physical altercations. The facility's policy on behavior management and response guidelines was not effectively followed. The resident's care plan, dated from 2021, lacked specific interventions to prevent the resident from physically assaulting others, being assaulted, and engaging in sexually inappropriate behaviors. Interviews with staff revealed that the resident's behaviors were known but not reported to the Director of Nursing or Administrator, and no protective measures or interventions were put in place. The facility's failure to address these behaviors led to repeated incidents of the resident being both the perpetrator and victim of physical and sexual misconduct. The facility's administration and interdisciplinary team were aware of the resident's ongoing behavioral issues but did not take adequate steps to manage them. The resident's inappropriate behaviors were not consistently documented or addressed in care plans, and there was a lack of communication and coordination among staff to ensure the resident's and other residents' safety. The facility's inaction and lack of effective intervention contributed to a failure to meet the resident's behavioral health needs, resulting in a deficiency in care.
Inadequate Staff Competency in Managing Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to provide appropriate and sufficient staff to meet the behavioral health needs of a resident with a known history of agitation, aggression, and sexually inappropriate behaviors. The resident, who resides in the Dementia Special Care Unit, exhibited severe cognitive impairment and engaged in behaviors such as wandering into other residents' rooms, physical aggression, and sexual misconduct. Despite these behaviors, the facility did not ensure that staff had the necessary competencies and skills to manage the resident's needs effectively, nor did they develop non-pharmacological interventions or care plans to address these issues. The report highlights multiple incidents where the resident's inappropriate behaviors were not adequately addressed by the staff. These incidents included physical and sexual abuse towards other residents and staff, with no protective measures or interventions put in place. Interviews with various staff members, including nurses and the Director of Nursing, revealed a lack of recognition of these behaviors as abuse and a failure to develop care plans to manage the resident's behaviors. The facility's policies on abuse prevention and behavior management were not effectively implemented, as evidenced by the lack of staff training and the absence of documented interventions. Furthermore, the facility's interdisciplinary team did not provide evidence of discussing or addressing the resident's behaviors to prevent further incidents. The staff development coordinator acknowledged a low completion rate for mandatory behavior training, indicating insufficient staff education on managing such behaviors. The facility's failure to address the resident's behavioral health needs and ensure staff competency resulted in ongoing incidents of abuse and neglect, compromising the safety and well-being of both the resident and others in the facility.
Failure to Implement Abuse Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its abuse policy for a resident with severe cognitive impairment and a history of aggressive and sexually inappropriate behaviors. The resident, who had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance, was involved in multiple incidents of physical and sexual abuse towards other residents. Despite these incidents, the facility did not notify the Director of Nursing (DON) or the Administrator, nor did they report the incidents to the state agency or law enforcement as required. Protective measures to prevent further abuse were not implemented, leaving both the resident and others at risk. The facility's policy required immediate reporting and investigation of abuse allegations, as well as the implementation of protective measures to ensure resident safety. However, the facility failed to adhere to these protocols. For instance, incidents where the resident hit other residents or exhibited sexually inappropriate behavior were not reported or investigated, and no protective interventions were put in place. The DON was unaware of these incidents, indicating a breakdown in communication and policy enforcement within the facility. Additionally, the facility did not ensure that all staff received the required training on abuse prevention and reporting. Only a small percentage of staff completed the mandatory training, which contributed to the failure to report and address the abuse incidents. The lack of coordination and communication with the Quality Assurance Performance Improvement (QAPI) program further exacerbated the issue, as there was no evidence of corrective action or tracking for cases of physical and sexual abuse. This systemic failure to follow established procedures and ensure staff training compromised the safety and well-being of the residents.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report multiple allegations of abuse and neglect involving a resident with severe cognitive impairment and behavioral disturbances. The resident, who had a history of agitation, aggression, and sexually inappropriate behaviors, was involved in five documented incidents of physical and sexual abuse, as well as neglect. These incidents included inappropriate sexual behavior towards female residents and staff, and physical altercations with other residents. Despite these occurrences, the facility did not report any of these incidents to the state agency or law enforcement as required by their policy. Interviews with staff revealed a lack of reporting and intervention regarding the resident's behaviors. Unit Manager #1 and Nurse #13 acknowledged the resident's aggressive and sexually inappropriate behavior but did not report these incidents to supervisors or the Director of Nursing. Nurse #11 admitted to documenting an incident where the resident was sexually inappropriate and physically abusive but did not take further action to report or implement protective measures. The Director of Nursing confirmed that all incidents should have been reported, and the Administrator acknowledged the failure to report these allegations to the appropriate authorities. The facility's policy mandates immediate reporting of abuse, neglect, and mistreatment to the state agency and law enforcement. However, the facility did not adhere to these requirements, as evidenced by the lack of reports in the Health Care Facility Reporting System for the incidents involving the resident. This failure to report and address the resident's behaviors resulted in a deficiency in the facility's compliance with regulatory requirements for reporting suspected abuse and neglect.
Failure to Investigate and Address Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate five allegations of abuse and neglect involving a resident with severe cognitive impairment and behavioral disturbances. The resident, who had a history of agitation, aggression, and sexually inappropriate behaviors, was involved in multiple incidents, including physical abuse and sexual harassment. Despite these incidents being documented in the medical record, no investigations were conducted, and no protective measures were implemented to prevent further occurrences. The resident, admitted in September 2021, exhibited behaviors such as wandering into other residents' rooms, physical aggression, and sexually inappropriate actions. These behaviors were documented in nurse's notes, including incidents where the resident smacked a female resident, intrusively entered rooms, and exposed themselves. Staff interviews revealed that these behaviors were considered baseline for the resident, and no interventions were put in place to protect other residents. Interviews with facility staff, including the Unit Manager, nurses, and the Director of Nursing, confirmed that the incidents were not reported or investigated as required by the facility's policy. The Administrator acknowledged the resident's history of altercations and sexual behaviors but could not explain why the allegations were not investigated. The lack of investigation and protective measures highlights a significant deficiency in the facility's handling of abuse and neglect allegations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to unmet medical, nursing, and psychosocial needs. Resident #77, who had severe cognitive impairment and a history of aggressive and sexually inappropriate behaviors, did not have a care plan addressing these behaviors. Despite multiple incidents of hitting other residents and being hit, as well as sexually inappropriate behavior, the care plan was not updated to include interventions to prevent these occurrences. The Director of Nursing acknowledged that care plans should have been developed to address these behaviors but were not. Resident #60, with moderate cognitive impairment and a history of hypersexual behaviors, also lacked an individualized care plan to address these behaviors. Despite being sent to the hospital twice due to these behaviors, no care plan was developed to manage or mitigate the risk. The Social Worker indicated that a care plan should be developed following behavioral incidents to ensure resident safety, but this was not done. Other residents, such as Resident #64, who used pillows and a floor mat to prevent falls, and Resident #25, who required a specific chair for meals, also lacked updated care plans reflecting these needs. Additionally, Resident #105, who exhibited wandering behaviors, did not have a care plan addressing this issue. The facility's failure to update care plans to reflect residents' current needs and behaviors was acknowledged by the Director of Nursing and other staff members, indicating a systemic issue in care plan management.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident identified as high risk for skin breakdown. Upon admission, the resident was assessed using the Norton Plus Pressure Ulcer Scale and scored an 8, indicating a high risk for pressure ulcer development. Despite this, the facility did not develop or implement a care plan with preventative measures to address this risk. The resident's medical record lacked documentation of a care plan upon admission, and subsequent assessments continued to show high risk scores without the implementation of preventative strategies. The resident developed a Stage III pressure ulcer on the right heel, which was first identified during a weekly skin assessment on September 11, 2024. The Unit Manager who identified the ulcer failed to develop a care plan with interventions to prevent further deterioration. The Wound Care Specialist recommended offloading boots and repositioning every two hours, but these recommendations were not implemented in a timely manner. The resident's condition worsened, with the ulcer becoming infected with MRSA, necessitating antibiotic treatment. Interviews with facility staff, including the Director of Nursing and the Wound Care Specialist, revealed that the facility did not have a care plan in place upon admission to prevent pressure ulcers. The Director of Nursing acknowledged that the lack of a care plan and preventative measures, combined with the resident's co-morbidities, likely contributed to the development of the pressure ulcer. The facility's failure to implement timely interventions and follow the Wound Care Specialist's recommendations resulted in the resident acquiring a facility-acquired Stage III pressure ulcer.
Failure to Address Behavioral Needs and Ensure Safety
Penalty
Summary
The facility failed to effectively utilize its resources to address the behavioral needs of a resident with a known history of aggressive and sexually inappropriate behaviors, resulting in an unsafe environment for other residents. The resident, admitted in September 2021, had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. The medical record indicated multiple incidents of aggression and inappropriate sexual behavior, including hitting other residents and sexually harassing staff and residents. Despite these incidents, the facility did not provide evidence of interventions or discussions by the interdisciplinary team to prevent further occurrences. The facility's policy on abuse, mistreatment, and neglect required staff training on abuse risk and prohibition practices, but the training completion rates were low, with only 30% of staff completing abuse training and 15% completing behavior training. The facility's assessment failed to indicate necessary education and competencies for staff, and the Quality Assurance Performance Improvement (QAPI) process did not analyze incidents of abuse and neglect to determine needed changes. The Administrator and DON acknowledged the lack of training compliance and the failure to address incidents through the QAPI process.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that included the necessary resources to provide both emergency and day-to-day care for its resident population. The assessment was not updated to meet the new requirements specified in the Centers for Medicare and Medicaid Services Quality Safety Oversight Memorandum (QSO-24-13-NH), which became effective in August 2024. The facility's assessment lacked critical information about the resident population, such as diseases, conditions, and cognitive limitations, which are essential for determining staffing needs and competencies. The facility assessment tool, last updated in December 2023 and reviewed with the Quality Assurance Performance Improvement (QAPI) committee in June 2024, was incomplete. Key sections, including those related to resident profiles, staff competencies, and facility resources, were left blank. The assessment did not involve active participation from key individuals such as direct care staff, residents, and families, as required by the new guidance. The Administrator and Director of Nurses (DON) were the only individuals involved in creating the assessment, and they acknowledged the missing information during interviews with the surveyor. Additionally, the facility did not incorporate a Hazard Vulnerability Analysis and Summary into the assessment, which is required to address potential emergencies and natural disasters. The Administrator admitted that the analysis was part of the facility's disaster plan but was not included in the facility assessment. Both the Administrator and the DON recognized that the current facility assessment did not meet the new requirements and contained numerous incomplete sections.
Deficiency in Effective Communications Training for Staff
Penalty
Summary
The facility failed to ensure that direct care staff received mandatory effective communications training, as evidenced by documentation review and interviews. The Facility Assessment reviewed by the Quality Assurance Performance Improvement committee did not indicate that Effective Communications Training was required. During interviews, the Administrator and the Director of Nurses (DON) were unable to provide the content of the training classes to the surveyors, indicating a lack of accessible documentation. The electronic training system curriculum showed that all staff were required to complete training on HIPAA, social media, and electronic communications, as well as communication with people with dementia. However, only therapy staff were required to complete a course on communicating effectively. The review of the facility's in-service and education records from November 2023 to November 2024 revealed that only 78 out of 163 staff members completed the communication training, resulting in a completion rate of 48%. The Staff Development Coordinator (SDC) expressed that the completion percentage was not acceptable and expected better compliance with training requirements. This deficiency highlights the facility's failure to ensure that all direct care staff received the necessary training to communicate effectively, which is crucial for providing quality care to residents.
Deficiency in Staff Training on Resident's Rights
Penalty
Summary
The facility failed to ensure that all staff members received training on Resident's Rights, as required by their policy on Abuse Prevention. The policy, revised in April 2017, mandates that training on abuse prevention, including Resident's Rights, be provided during orientation and on an ongoing basis. However, upon review of the facility's training records from November 2023 to November 2024, it was found that only 16 out of 163 staff members completed the required Resident's Rights training, resulting in a completion rate of just 10%. During interviews, the Administrator was unable to provide the content of the training classes to the surveyors, and the Staff Development Coordinator expressed surprise and concern over the low completion rate, acknowledging that the compliance with training requirements was not acceptable. The Director of Nurses provided the survey team with the electronic training system's annual curriculum, which included the Essentials of Resident's Rights, but the facility's records indicated a significant deficiency in ensuring that all staff completed this essential training.
Inadequate Staff Training on Abuse Prevention
Penalty
Summary
The facility failed to ensure that all staff were adequately trained in the standards, policies, and procedures for abuse prevention and reporting protocols. The facility's policy, revised in April 2017, mandates training for all staff on abuse prevention, including recognizing and managing burnout, frustration, and stress that may lead to abuse. Despite this, a review of the facility's training records revealed that only 50 out of 163 staff members completed the required abuse training in the last 12 months, resulting in a completion rate of just 30%. During interviews, the Administrator was unable to provide the content of the training classes to the surveyor, and the Staff Development Coordinator acknowledged the low completion rate, stating it was not acceptable. The electronic training system curriculum indicated that all staff were required to complete courses on elder abuse, preventing, recognizing, and reporting abuse, and managing stress. However, the facility's failure to ensure comprehensive staff training on these critical issues led to a deficiency in their compliance with abuse prevention protocols.
Inadequate QAPI Training Compliance
Penalty
Summary
The facility failed to provide adequate training and education to their staff regarding the elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program. During a survey, the Administrator was unable to provide the content of the training classes to the surveyors, although a list of 163 staff members was provided. The Director of Nurses (DON) presented the electronic training system's annual curriculum, which included a course on the implementation of QAPI programs. However, a review of the facility's in-service and education records revealed that only 17 out of 163 staff members completed the QAPI training in the past 12 months, resulting in a completion rate of just 10%. The Staff Development Coordinator (SDC) acknowledged the low completion rate and expressed that it was unexpectedly low and unacceptable.
Inadequate Staff Training on Infection Control
Penalty
Summary
The facility failed to ensure that all staff were trained on the standards, policies, and procedures for the infection prevention and control program. During an interview, the Administrator provided the survey team with printouts of staff training records from the electronic training system but was unable to provide the content of the classes. The facility's electronic training system curriculum required all staff to complete courses on infection control and prevention, personal protective equipment, bloodborne pathogens, and hand hygiene. However, a review of the facility's in-service and education records revealed that only 50 out of 163 staff members completed the required infection control training in the last 12 months, resulting in a completion rate of 32%. The Staff Development Coordinator acknowledged the low completion rate and deemed it unacceptable.
Failure to Provide Corporate Compliance Training
Penalty
Summary
The facility failed to provide staff training on their ethics standards, policies, and procedures, resulting in a deficiency. During an interview, the Administrator provided the survey team with printouts of staff training completed in the last 12 months but was unable to provide the content of the classes. A list of 163 staff members was also provided. The Director of Nurses (DON) presented the electronic training system's annual curriculum, which included a requirement for all staff to complete 'Basics of Corporate Compliance.' However, a review of the facility's in-service and education records from November 2023 to November 2024 showed no evidence that any current active staff had completed Corporate Compliance training in the last 12 months. The Staff Development Coordinator (SDC) acknowledged the lack of training and was unaware that it was a required training, with no further records available.
Failure to Maintain CNA Training Records
Penalty
Summary
The facility failed to maintain records of certified nurse aide (CNA) trainings for continuing competency, which is required to include no less than 12 hours of mandatory training per year for each CNA employed. During the survey, the Administrator provided the survey team with printouts of staff training completed on their electronic training system over the last 12 months but was unable to provide the content of the classes. The Director of Nurses (DON) provided the electronic training system's annual curriculum, which outlined a total of 22.75 hours of training for all staff and an additional 5 hours specifically for CNAs. However, the Staff Development Coordinator (SDC) admitted to not tracking CNA training hours and was unaware of the requirement, relying solely on the electronic system to document training hours without the ability to include in-person in-services. Upon request, the facility could not provide proof of the required 12 hours of training for five CNAs who interacted with the survey team. The DON acknowledged the inability to provide documentation of the training hours for the requested CNAs, and the SDC confirmed that the CNAs likely had not completed the required training hours. The SDC recognized that the facility was out of compliance with the training requirements for CNAs, indicating that the training program was still a work in progress.
Behavioral Health Training Deficiency
Penalty
Summary
The facility failed to provide behavioral health training and education to their staff, as required by regulations. The Facility Assessment, reviewed by the Quality Assurance Performance Improvement committee, did not indicate that behavioral health trainings were necessary. During an interview, the Administrator was unable to confirm if a training plan existed and could not provide the content of the classes to the surveyor. The facility's electronic training system showed that only 24 out of 163 staff members completed some form of behavioral health training, resulting in a completion rate of 15%. The Staff Development Coordinator acknowledged the low completion rate for behavioral health trainings and expressed that the compliance was not acceptable. The electronic training system curriculum included courses such as Dementia Care, Alzheimer's Disease and Related Disorders, and Communication with People with Dementia, but the facility's records indicated insufficient participation in these trainings. The deficiency was identified during a survey, highlighting the facility's failure to ensure staff received necessary behavioral health education.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of significant health conditions. Resident #64, who was admitted with a Stage 3 pressure ulcer and dementia, experienced a significant weight loss of over 10% from May 2024 to November 2024. However, the MDS assessment dated November 11, 2024, did not reflect this weight loss, nor did it accurately document the Stage 3 pressure ulcer, instead coding it as a Stage 1. Interviews with the Registered Dietitian and MDS Nurse confirmed these inaccuracies. Resident #25, admitted with dysphagia, adult failure to thrive, and dementia, also experienced a significant weight loss of 18.92% over six months. Despite this, the MDS assessment failed to indicate a 10% weight loss in 180 days. The Registered Dietitian acknowledged the oversight during an interview, confirming that the weight loss should have been coded as significant on the MDS. Resident #2, with diagnoses including bipolar disorder and mood disorder, had a wound on the right foot that was not documented in the MDS assessment. Although the treatment for the wound was discontinued on September 5, 2024, a dressing change occurred within the seven-day look-back period, which should have been included in the MDS. MDS Nurse #1 confirmed the omission during an interview, acknowledging that the MDS was inaccurate in this regard.
Failure to Rotate Injection Sites and Obtain Physician's Order for Hospital Transfer
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of two residents. For one resident, the facility did not rotate the injection sites for intramuscular antibiotic administration, as recommended by the National Institute of Health to prevent lipohypertrophy and ensure proper medication absorption. The resident, who had a history of urinary tract infections and cognitive impairments, received Rocephin injections without documentation of site rotation in the medical records. Interviews with nursing staff and the Director of Nursing confirmed the absence of documentation and the failure to follow proper procedures for injection site rotation. For another resident, the facility did not obtain a physician's order for a hospital transfer following a change in the resident's surgical wound condition. The resident, who was cognitively intact, was transferred to the hospital for a potential wound dehiscence without a documented physician's order. Interviews with the Regional Nurse, Medical Records Coordinator, and Director of Nursing revealed that the facility lacked a policy on obtaining physician's orders for transfers, and the required order was missing from the resident's medical record.
Physician Order Signing Deficiency
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders for a resident, leading to a deficiency. The resident, who was admitted in September 2023, had diagnoses including dementia, depression, and bipolar disorder. A review of the resident's medical records revealed that the physician last signed the orders in January 2024, with no additional orders signed thereafter. A binder at the nursing station contained unsigned physician's orders from February 2024 to October 2024, indicating a lapse in the physician's responsibility to review and sign the orders. Interviews conducted during the survey revealed that the nurse confirmed the presence of unsigned orders in the binder and noted that the physician did not visit the facility frequently. The Director of Nursing acknowledged awareness of the physician's backlog in signing orders. The physician himself stated that he signs orders if they are in the resident's chart but was unaware of the binder with his name on it. This lack of communication and oversight contributed to the deficiency in ensuring timely physician review and signature of resident orders.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to comply with the requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, without any nurse staffing waivers in place. This deficiency was identified during a survey conducted between 11/1/24 and 11/18/24. The review of nursing schedules revealed that on several days, specifically Saturdays and Sundays, there was no RN present for the required hours. The Staff Scheduler confirmed that although an RN was present, they did not work the full eight consecutive hours on those days. Additionally, the Director of Nursing (DON) was not scheduled or documented as working on those days, despite being available if issues arose. The DON acknowledged the failure to meet the staffing requirement during an interview.
Failure to Act on Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to act promptly on recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two residents. For one resident, the pharmacist did not identify and report irregularities related to the administration of Clonazepam, a benzodiazepine medication used to treat anxiety. The resident had a moderate cognitive impairment and was receiving Clonazepam without a stop date, which was not flagged by the pharmacist during multiple MRRs. The pharmacist acknowledged the oversight during an interview. For another resident, the facility did not ensure that the physician reviewed and addressed the pharmacist's recommendations for a gradual dose reduction (GDR) of the antipsychotic medication Seroquel. Despite repeated recommendations from the pharmacist to re-evaluate the continued use of Seroquel at its current dose, the physician did not document a response or take action. The resident had diagnoses including dementia, depression, and bipolar disorder, and was receiving Seroquel as prescribed. The physician admitted to not addressing the pharmacist's recommendations during an interview.
Food Safety and Sanitation Deficiencies in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. The surveyor observed multiple instances where thickened beverage items were not properly dated and stored across three kitchenettes. Specifically, opened containers of thickened apple juice, water, cranberry juice, orange juice, dairy beverages, and lactose-free milk were found undated and improperly stored, with some items being kept at room temperature or frozen against manufacturer recommendations. The Food Service Director (FSD) acknowledged that the expectation was for all thickened liquids to be stored according to the manufacturer's guidelines and for refrigerators to be checked regularly for expired items. Additionally, the facility did not ensure that staff refrained from eating in the kitchenettes designated for resident use. During the survey, two staff members were observed eating pizza in the Second Floor Kitchenette, leaving their food on a shelf with resident snack supplies. The FSD confirmed that staff should not eat in the kitchenettes and that there was a designated staff dining room for employee meals. The Director of Nursing (DON) reiterated that it was unacceptable for staff to eat or store food in the kitchenettes, as these areas are intended for resident use only. These observations indicate a failure to comply with the 2022 Food Code by the Food and Drug Administration (FDA), which outlines the importance of proper food storage and employee accommodations to prevent contamination. The lack of proper labeling and storage of food items, along with staff eating in resident-designated areas, highlights significant lapses in maintaining food safety and sanitation standards within the facility.
Deficiencies in Timely Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for four residents. For Resident #25, the medical records did not contain a copy of the Health Care Proxy Form and HCP Activation Form, and there was a significant delay in documenting physician visits. The Director of Nursing acknowledged the absence of these documents and the expectation for complete medical records. Physician #1 admitted to delays in sending over notes, which contributed to the incomplete records. Resident #64's medical records showed a 215-day gap between documented physician visits, despite the physician claiming to have seen the resident during this period. The Medical Records Clerk confirmed that notes were faxed but not always filed in the records. Similarly, Resident #83's records lacked timely documentation of physician visits, with a 224-day gap noted. The physician and his extender claimed to have sent notes, but they were not consistently filed in the resident's records. For Resident #102, the medical records were missing several physician progress notes, with only three visits documented since admission. The Unit Manager and DON confirmed the absence of additional notes, and efforts to locate them were unsuccessful. Physician #1 acknowledged the need to send over missing notes. These deficiencies highlight a systemic issue in the timely filing and maintenance of medical records, impacting the accuracy and completeness of resident care documentation.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement, included in the admission packet, was explained to residents or their representatives in a manner they could understand. This deficiency was identified for two residents who had signed the arbitration agreements without a clear understanding of the document's implications. The facility's policy required that the agreement be explained to the resident or responsible party, but interviews revealed that this was not consistently done. The Administrator and Social Worker were responsible for reviewing the agreement with residents, but there was no documentation to confirm that residents understood what they were signing. Interviews with the residents involved indicated that they were unaware of the arbitration agreement's purpose and implications. One resident stated they did not recall anyone explaining the agreement to them and expressed a desire to retain the right to litigation. Another resident did not know what arbitration was and had not received an explanation from the facility staff. The Social Worker involved admitted to not reviewing the agreement with residents or educating them about it, contrary to the Administrator's claims. This lack of proper explanation and documentation led to the deficiency identified by the surveyors.
Facility's Arbitration Agreement Lacks Clarity on Neutral Arbitrator Selection
Penalty
Summary
The facility failed to ensure their arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties, as required by federal regulations. During the survey, it was found that the facility's Arbitration Agreement, last revised in February 2022, did not explicitly state that residents or their representatives had the right to select a neutral arbitrator. The Administrator confirmed that the current version of the agreement did not include this provision and was unaware that it was a federal requirement, mistakenly believing it was governed by state regulations. The agreement referenced the American Arbitration Association (AAA) but did not clarify the residents' rights regarding the selection of a neutral arbitrator. Interviews with residents revealed a lack of understanding and awareness about the arbitration process and the AAA. Residents expressed confusion about the AAA, with some not knowing if it was a website or how to access it. They indicated that the arbitration agreement was not explained to them in understandable terms, and they were not familiar with navigating online resources to obtain further information. This lack of clarity and accessibility in the arbitration agreement contributed to the deficiency identified by the surveyors.
Failure to Implement Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, focusing on quality of life, quality of care, and services to residents. Specifically, the facility did not ensure an ongoing QAPI program was in place to address identified priorities, including ongoing concerns of physical and sexual abuse involving a resident. The facility's policy indicated that the Quality Assessment and Assurance (QAA) Committee should meet quarterly to identify quality deficiencies and develop plans of action, but this was not effectively executed. The resident involved, admitted in September 2021, had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. The medical record showed a history of agitation, aggression, intrusive wandering, hitting other residents, and sexually inappropriate behaviors. Despite these ongoing issues, the facility failed to provide evidence that the interdisciplinary team discussed and addressed the resident's behaviors or implemented interventions to prevent further incidents. Interviews with the Director of Nursing (DON) and the Administrator revealed awareness of the resident's history of aggression and inappropriate behaviors. However, the Administrator was unable to provide evidence of any action plans or interventions put in place to address these issues. The QAA committee's activities, as reported by the Administrator, did not include addressing the concerns of physical and sexual abuse, nor did they develop and implement plans to correct these deficiencies, ensuring the safety of the resident and others in the facility.
Infection Control Deficiencies in Surveillance, Water Management, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. The infection preventionist (IP) did not maintain a complete and accurate system of surveillance, as the surveillance line listings for multiple residents were incomplete and inaccurate. For instance, Resident #51's listing for pneumonia lacked sufficient signs and symptoms to meet the McGeer criteria, and critical information such as culture date, site, and results were left blank. Similar issues were found with Resident #97 and Resident #40, where the documentation did not meet the criteria for urinary tract infection and skin infection, respectively, and essential data was missing. Additionally, the facility did not have an up-to-date water management plan to prevent the growth and spread of Legionella and other opportunistic pathogens. The last documented water management plan was dated 1/1/22, and there was no evidence of a plan for 2023 or 2024. The administrator acknowledged that the plan was outdated and that the team listed in the plan was no longer accurate, indicating a lack of proper oversight and updating of critical safety protocols. Furthermore, the facility failed to ensure proper hand hygiene practices during a dressing change for a resident with a pressure ulcer. Nurse #3 did not perform hand hygiene between glove changes and after cleansing the wound, which is a critical step in preventing infection. The DON confirmed that the nurse should have performed hand hygiene at these points, highlighting a lapse in adherence to infection control procedures during direct patient care.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required, leading to the inappropriate use of antibiotics for several residents. The facility's policy on antibiotic stewardship, last revised in December 2023, outlines the need for monitoring antibiotic use to decrease unnecessary utilization. However, the facility did not adhere to its own protocols, as evidenced by the lack of documentation justifying continued antibiotic use for residents whose symptoms did not meet the McGeer criteria for infection. Specifically, residents were prescribed antibiotics despite surveillance indicating their conditions did not rise to the level of infection, and there was no documented reasoning for the continued use of antibiotics in their medical records. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged during interviews that the facility's antibiotic stewardship program was not being followed. The IP stated that antibiotic usage is tracked and reviewed daily, but the medical records for the residents in question did not reflect the necessary documentation to justify continued antibiotic therapy. The DON confirmed that physicians and nurse practitioners need to document when continued antibiotic use is warranted, even if the symptoms do not meet the established criteria. The lack of documentation and adherence to the stewardship program resulted in the deficiency noted by the surveyors.
Resident's Right to Smoke Not Facilitated
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not allowing them to exercise their right to smoke. The resident, who was previously able to smoke independently on the first floor, was moved to the second floor after returning from a hospital stay. This move required staff assistance for the resident to access the designated smoking area due to the need for a key to operate the elevator. Despite the resident's expressed desire to smoke, staff did not facilitate this, and there was no documented plan to address the resident's smoking needs. Interviews with the resident revealed their frustration and feeling of being restricted, as they were not allowed to smoke independently as they had been on the first floor. The resident expressed that they felt like a prisoner and that their rights were being violated. The resident also mentioned that they were told by the administrator that their situation would be reviewed in 30 days, which they found unacceptable. The resident's care plan did not reflect any current restrictions or concerns related to smoking, and there was no documentation of an agreement that the resident would not smoke while on the second floor. Staff interviews indicated a lack of communication and understanding regarding the resident's smoking rights. The unit manager and nurses were aware of the resident's desire to smoke but did not take action to facilitate it. The social worker confirmed that the resident should be allowed to smoke and that the ombudsman had advised that the resident had the right to smoke, even in a non-smoking facility. The administrator was unaware of the resident's concerns and stated that there was a disconnect with staff regarding the resident's smoking rights.
Failure to Facilitate Change in Resident's MOLST Form
Penalty
Summary
The facility failed to ensure that a resident's representative was able to exercise the resident's rights regarding medical decisions, specifically in changing the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form. The resident, who was admitted with diagnoses of encephalopathy and cerebral infarction, was determined by a physician to lack the capacity to make healthcare decisions. The resident's MOLST form, signed by the Health Care Proxy (HCP), indicated a Do Not Resuscitate (DNR) status, among other directives. Despite the resident's representative expressing a desire to change the MOLST to reflect a Full Code status, the facility did not facilitate this change. The representative faced difficulties in visiting the facility to amend the MOLST due to transportation issues, and the facility did not offer alternative methods for amending the form, such as mailing a new MOLST or having it delivered. Interviews with facility staff, including nurses and a nurse practitioner, confirmed that the representative was informed that the only way to change the MOLST was by physically coming to the facility to sign a new form. The Director of Nursing later acknowledged that the MOLST could have been voided by two nurses to change the status to Full Code, or a new MOLST could have been mailed or delivered to the representative. However, these options were not initially provided, resulting in the resident remaining under a DNR status contrary to the representative's wishes.
Failure to Notify Physician of Medication Delay
Penalty
Summary
The facility failed to notify the physician of a delay in administering an intramuscular antibiotic medication as ordered for a resident. The resident, who had a history of urinary tract infections, was diagnosed with a UTI caused by E. coli. The physician ordered Rocephin 1 gram IM daily for three days. However, due to a holiday, the pharmacy could not deliver the medication on time, and the nurse did not have access to the electronic medication dispensing system. The nurse did not notify the physician about the unavailability of the medication, resulting in the resident not receiving the first dose as scheduled. The nurse's notes did not document any notification to the physician or the nursing supervisor about the medication delay. Interviews with the nurse, unit manager, and DON confirmed that the physician was not informed about the medication not being administered as ordered. The physician later confirmed that he was unaware of the delay. This lack of communication and failure to follow the facility's policy on notifying the physician of changes in condition led to the deficiency.
Resident Involuntarily Secluded by Stop Sign Banner
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion. During the day shift, staff applied a stop sign banner secured with Velcro strips across the entry door to the resident's room, preventing the resident from leaving. The resident, who had diagnoses including unspecified dementia with behaviors, anxiety, and major depression, was observed multiple times attempting to remove the banner and leave the room but was unable to do so. The resident's behavior plan indicated interventions for wandering, but the use of the banner was not intended for this resident. Interviews with staff revealed that the stop sign banner was intended to prevent another resident from entering the room and disturbing a different resident. However, the banner inadvertently restricted the resident's ability to leave the room, effectively acting as a restraint. The Director of Nursing acknowledged that the banner was not needed since the other resident was on one-to-one supervision and could be redirected if necessary. The facility's policy on abuse prevention indicated that residents have the right to be free from involuntary seclusion, which was not upheld in this instance.
Failure to Document Resident's Course of Illness and Treatment
Penalty
Summary
The facility failed to document the recapitulation of a resident's stay, which included the course of illness and treatment, for a resident who was admitted for chronic obstructive pulmonary disease (COPD) and discharged after a brief stay. The resident, who signed out against medical advice, expressed a desire to return home to manage their illness, as they had done in the past. Despite the resident's discharge over 30 days prior, the medical record lacked a recapitulation of the stay by the attending physician. During the review of the closed medical record, the Medical Records Coordinator confirmed the absence of physician notes or a recapitulation of the resident's stay. Although an admission note was found, the required documentation of the resident's course of illness and treatment was not completed by the physician, contrary to the facility's policy and state law requirements. This oversight was identified during staff interviews and record reviews, highlighting a deficiency in the facility's discharge documentation process.
Failure to Administer Prescribed Antibiotic Treatment
Penalty
Summary
The facility failed to administer antibiotic treatment as ordered by the physician for a resident with a urinary tract infection (UTI). The resident, who had a history of UTIs and cognitive impairments, was prescribed an intramuscular injection of Rocephin 1 gram daily for three days. However, due to a holiday, the pharmacy could not deliver the medication, and the nursing staff did not access the facility's electronic medication dispensing system to obtain the medication. This resulted in a delay in the administration of the prescribed treatment. The nurse involved did not notify the physician about the unavailability of the medication and failed to ensure that the medication was accessed from the electronic dispensing system. Interviews with the Unit Manager and the Director of Nursing (DON) revealed that there were nurses with access to the system, and the expectation was to contact a supervisor or the DON if access was needed. Despite this, the medication was not administered as ordered, and the resident did not receive the first dose of Rocephin until the following day.
Failure to Perform Ordered Bladder Scan for Resident
Penalty
Summary
The facility failed to implement services to assess urinary incontinence for Resident #63, who was admitted with diagnoses including type 2 diabetes mellitus and essential hypertension. The resident, who was cognitively intact, reported experiencing urinary urgency, frequency, and dribbling for three months. A physician's order for a bladder scan after voiding was issued, but the facility did not perform the scan as ordered. The Treatment Administration Record (TAR) lacked documentation of the scan, and there was no indication that the physician was notified of the failure to perform the procedure. Interviews with facility staff revealed a lack of awareness regarding the resident's urinary issues and the physician's order for a bladder scan. The Director of Nursing confirmed that the scan was not documented, indicating it was not performed. The Unit Manager and Director of Nursing acknowledged the missing documentation and the absence of a rationale for not completing the scan. The physician was unaware that the scan had not been conducted, and the resident confirmed that the procedure was not performed. The deficiency was identified after surveyor intervention, highlighting a failure in communication and documentation within the facility.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that Resident #83 was seen by a physician at the required intervals following admission. According to the facility's policy, a resident should be seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner as indicated. Resident #83, who was admitted in March 2022 with diagnoses including hypertension, diabetes, and dementia, was last documented to have been seen by a physician on 3/4/24. However, there was no further documentation of physician visits until 10/14/24, resulting in a 224-day gap between visits. During interviews, Physician #4 claimed to have seen Resident #83 after 3/4/24 but could not recall specific dates, and the Director of Nursing acknowledged that the physician should have seen the resident at least every 120 days. The facility's failure to adhere to the required schedule for physician visits led to a deficiency in providing timely medical assessments and care for Resident #83.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with dementia. The facility's policy on the care of residents with dementia, last revised in February 2017, mandates ongoing comprehensive assessments and individualized care plans for residents with dementia. However, a review of the medical record for a resident admitted in September 2021 with a diagnosis of dementia revealed the absence of an active care plan addressing the resident's dementia care needs. The Minimum Data Set (MDS) assessment indicated the resident had severely impaired cognitive skills and exhibited behavioral symptoms, yet no individualized interventions were documented. Interviews with facility staff, including a Unit Manager and the MDS Coordinator, confirmed the deficiency. The Unit Manager stated that MDS nurses are responsible for initiating dementia care plans upon admission. The MDS Coordinator acknowledged that the MDS department is tasked with developing comprehensive care plans based on the MDS assessment process. However, she admitted that the resident in question did not have a care plan developed for their dementia care needs. An audit conducted by the facility revealed that several residents were missing care plans, indicating a broader issue with care plan implementation.
Failure to Manage Psychotropic Medications Appropriately
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not limit the use of a PRN anti-anxiety medication, Clonazepam, to 14 days or provide a documented clinical rationale and duration for extending its use. The resident, who had a moderate cognitive impairment, received Clonazepam on multiple occasions over several months without a stop date or re-evaluation of the medication's necessity. Interviews with nursing staff, a nurse practitioner, a physician, a pharmacist, and the Director of Nursing confirmed the absence of a stop date and the need for re-evaluation of the medication. For another resident, the facility did not attempt a gradual dose reduction (GDR) of the antipsychotic medication Seroquel, nor did the physician document a clinical contraindication for not attempting a GDR. The resident, who had dementia, depression, and bipolar disorder, was receiving Seroquel as prescribed, but the physician did not follow up on a psychiatric clinician's recommendation to decrease the dose. The physician admitted to not addressing the recommendation or documenting a rationale for declining a GDR.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications and biologicals, as observed by surveyors. In one instance, a nurse stored a resident's refused morning medications in a plastic cup within the top drawer of a medication cart, contrary to the facility's policy. The nurse admitted to keeping the medications to attempt administration later, without disposing of them or documenting the refusal as required. The Director of Nurses confirmed that this practice was unacceptable and did not align with the facility's expectations for medication administration and storage. Additionally, the facility did not secure treatment carts when not under the direct supervision of a licensed nurse. Surveyors observed an unlocked and unattended treatment cart on the Third Floor Unit multiple times, with residents, including those with dementia, walking nearby. The Unit Manager acknowledged that the treatment cart should always be locked when not in use, and the Director of Nurses reiterated that all treatment and medication carts should be secured to prevent unauthorized access.
Failure to Update and Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was updated daily and included the required details such as the current date and actual hours worked per shift for licensed and unlicensed staff, including RNs, LPNs, and CNAs. On 11/18/24, a surveyor observed that the nurse staffing document posted in the main lobby was outdated, showing information from 11/14/24. The document did not include the total hours worked for each category of staff, only the total number of staff. Interviews with the Housekeeping Manager, Director of Nursing (DON), and Staff Scheduler confirmed that the staffing report had not been updated daily as required. The Staff Scheduler, who was responsible for posting the staffing information during the orientation of a new staffing coordinator, admitted that she had not updated the report since 11/14/24, although she had prepared the reports for the weekend. She also stated that she was instructed by the Administrator to exclude the total hours worked from the report, contrary to the requirements. The DON acknowledged that the staffing report should include both the total number of staff and the total hours worked for each shift, indicating a lapse in compliance with the staffing information posting requirements.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare coverage to two residents, leading to a deficiency in compliance with regulatory requirements. Resident #60, who was admitted in February 2024, received Medicare A Skilled Benefits from June 3, 2024, until August 1, 2024. However, the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) when the discharge from Medicare A was initiated before benefits were exhausted. A handwritten note indicated that the social worker did not provide these notices to the resident or inform them of their potential financial responsibility. Similarly, Resident #163, admitted in May 2024, received Medicare A Skilled Benefits from May 16, 2024, until May 21, 2024. The discharge from Medicare A was voluntary, yet the facility failed to issue a NOMNC. A handwritten note on the SNF Beneficiary Protection Notification Review form indicated that the social worker did not communicate the discharge to initiate the non-coverage notice. During an interview, the Business Office Manager confirmed that the required notices were not issued to both residents, attributing the oversight to the social worker responsible at the time.
Failure to Provide Transfer/Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to issue a Notice of Transfer/Discharge to two residents, one of whom was transferred to the hospital following a fall and the other following a surgical wound complication. Resident #109, who had severe cognitive impairment, was transferred to the hospital in October 2024, but there was no documentation of a Notice of Transfer/Discharge being completed or provided to the resident or their family. Similarly, Resident #65, who was cognitively intact, was transferred to the hospital in November 2024, but did not receive a transfer notice and decided to discharge home instead of returning to the facility. Additionally, the facility did not ensure that the Ombudsman's office received copies of all resident notices of transfers as required. The Ombudsman reported not receiving any transfer or discharge notices since the end of August 2024, despite the facility's awareness of the requirement to send them. The Director of Nurses and the part-time Social Worker were unaware that the notices were not being sent to the Ombudsman office, which should occur at least monthly. The absence of a full-time social worker may have contributed to these deficiencies.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
