Brentwood Rehabilitation And Healthcare Ctr (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Danvers, Massachusetts.
- Location
- 56 Liberty Street, Danvers, Massachusetts 01923
- CMS Provider Number
- 225223
- Inspections on file
- 14
- Latest survey
- April 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brentwood Rehabilitation And Healthcare Ctr (the) during CMS and state inspections, most recent first.
A facility failed to maintain a medication error rate below 5%, resulting in a 15.38% error rate. Errors included incorrect dosing of Vitamin D3, administering the wrong medication and incorrect dosing of Psyllium, and administering Sevelamer Carbonate after a meal instead of with it. These errors affected three cognitively intact residents, as confirmed by the nursing staff and DON.
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care. A resident's treatment for a toe wound was not documented correctly, another resident's cast care was inaccurately recorded after the cast was removed, a third resident's blood pressure was not consistently documented before administering medication, and a fourth resident's blood pressure was incorrectly recorded on a restricted arm. Interviews confirmed these documentation errors.
A resident with intact cognition was observed exposed in their room, visible from the hallway, on two consecutive mornings. Despite numerous staff members passing by, no action was taken to cover the resident or close the door, violating the facility's dignity policy. Interviews with staff confirmed the expectation to maintain resident privacy and dignity.
A resident with PTSD and other conditions reported staff sleeping during night shifts, but the facility failed to file a grievance despite being aware of the complaint. Interviews with staff, including the Administrator and DON, confirmed awareness of the issue, yet no formal grievance was documented, violating the resident's rights.
The facility failed to implement physician orders for three residents, including not completing a prescribed toe treatment, lacking a physician order for a boot immobilizer, and not obtaining weekly weights. Observations and interviews confirmed these deficiencies, highlighting lapses in care and documentation.
A facility failed to follow physician orders for daily weights and notify a physician of a significant weight gain for a resident with liver cirrhosis. The resident experienced a 12.2 lb weight gain over four days, but weights were not recorded on three days, and the weight gain was not reported to the nurse practitioner. The facility's policy required confirmation and reporting of significant weight changes, which was not adhered to.
A facility failed to implement necessary interventions for a resident with severe cognitive impairment and pressure ulcers. Despite the care plan requiring an air mattress and Prevalon boots, observations showed the resident on a standard mattress without the prescribed equipment. Staff interviews revealed a lack of awareness and implementation of the care plan, which was confirmed by the unit manager and DON.
A resident with severe cognitive impairments and significant weight loss was not assessed by the dietitian for further interventions, despite facility policy requiring such action. The resident lost 7.25% of their weight in one month, but the dietitian was not informed, and the Director of Nursing was unaware of the weight loss, leading to a lack of timely dietary interventions.
The facility failed to maintain proper care of PICC lines for two residents, resulting in deficiencies in intravenous therapy administration. One resident's dressing was obscured by gauze, preventing site visualization, while another's dressing was lifting and not changed as required. The facility's policy was not followed, and documentation discrepancies were noted.
A resident received Vancomycin four times daily instead of the prescribed twice daily due to a failure to discontinue an original order when a new order for a different brand was obtained. This error was identified through record reviews and staff interviews, confirming the administration of both Vancomycin HCl Oral Suspension and Firvanq Oral Solution concurrently.
The Foodservice Director (FSD) failed to follow proper food handling practices, leading to potential contamination. The FSD was observed touching a garbage can lid with bare hands and then handling resident meal trays without washing her hands. Despite acknowledging the need for hand hygiene, the FSD did not wash her hands until later in the process.
The facility failed to ensure proper disinfection of shared resident equipment, as observed with two nurses during medication passes. One nurse used a blood pressure cuff and pulse oximeter on multiple residents without disinfecting them between uses, while another nurse did not sanitize a blood pressure cuff before or after use. This was contrary to facility policy and CDC guidelines, as confirmed by management.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 15.38% during the survey. This was due to errors made by three out of four nurses observed, affecting three residents. For one resident, a nurse administered an incorrect dose of Vitamin D3, giving 5000 units instead of the prescribed 1000 units. This resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Another resident was affected when a nurse administered the wrong medication, Banatrol Plus instead of Juven, and failed to measure the correct dose of Psyllium. The nurse mistakenly believed a heaping teaspoon was equivalent to the prescribed 3.4 grams. The medication packets were stored incorrectly, contributing to the error. This resident was also cognitively intact, with a BIMS score of 13 out of 15. A third resident received their medication, Sevelamer Carbonate, after a meal instead of with it, as per the physician's order. The medication was administered 1 hour and 20 minutes late, after the resident had finished dinner. This resident, too, was cognitively intact, with a BIMS score of 15 out of 15. The errors were acknowledged by the nursing staff and the Director of Nursing, who confirmed the deviations from the prescribed medication administration protocols.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care. For Resident #44, the facility did not accurately document the completion of a physician-ordered treatment for the resident's left great toe. Despite the treatment being recorded as administered on the Treatment Administration Record (TAR), observations and interviews revealed that the dressing was not applied as ordered, and the resident confirmed infrequent dressing changes. Resident #80's records inaccurately documented cast care, even though the cast had been removed weeks prior. The Treatment Administration Record continued to show that cast care was being signed off, despite the absence of a cast. Interviews with nursing staff confirmed that the order was not updated, and the documentation was incorrect. For Resident #106, the facility failed to ensure that blood pressure readings were consistently documented before administering midodrine, as required by the physician's order. The Medication Administration Record indicated the medication was given, but there was a lack of corresponding blood pressure documentation. Additionally, Resident #115's records inaccurately documented blood pressure readings taken on the right arm, despite orders prohibiting such due to the presence of an arteriovenous fistula. Interviews confirmed these inaccuracies in documentation.
Resident Privacy and Dignity Violation
Penalty
Summary
The facility failed to provide a dignified existence for a resident diagnosed with Bipolar disorder and personality disorder, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status. The deficiency was observed when the resident was found sleeping in their bed, visible from the hallway with the bedroom door open, wearing only briefs, and later completely naked. This exposure occurred on two consecutive mornings, with numerous staff members walking past the room without intervening to cover the resident or close the door. The facility's policy on dignity, revised in February 2021, emphasizes that residents should be treated with dignity and respect at all times. However, the lack of a privacy curtain and the staff's inaction in addressing the resident's exposure violated this policy. Interviews with a nurse and the Director of Nursing confirmed that staff should have intervened to maintain the resident's privacy and dignity, acknowledging the failure to do so in this instance.
Failure to File Grievance for Resident's Complaint
Penalty
Summary
The facility failed to file a grievance for a resident who expressed a complaint about staff sleeping during the night shift. The resident, who was admitted with diagnoses including diabetes, anxiety, and post-traumatic stress disorder, was cognitively intact and reported that staff were 'horrendous' and took a long time to respond to call bells. The resident also mentioned having photos of staff members sleeping during the night shift. Despite these complaints, the facility's grievance log did not include any documentation of a grievance being filed on behalf of the resident. Interviews with various staff members, including the Administrator, Nurse #8, Unit Manager #1, the Social Worker, and the Director of Nursing (DON), revealed that they were all aware of the resident's complaints. The Social Worker had informed both the Administrator and the DON about the complaints and stated that a grievance should have been completed. However, the Administrator admitted to not completing a grievance, and the DON confirmed that either the Social Worker or the Administrator was responsible for filing grievances. The facility's policy on grievances clearly outlines the process for filing and investigating grievances, including the role of the Administrator as the grievance officer. Despite this policy, the facility failed to adhere to its procedures, resulting in the resident's complaint not being formally addressed. The lack of action in filing a grievance represents a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by the facility's policy.
Failure to Implement Physician Orders and Document Care
Penalty
Summary
The facility failed to implement physician orders for three residents, leading to deficiencies in care. For one resident, the facility did not complete a prescribed treatment for the left great toe, which involved a normal saline wash, application of bacitracin, and covering with a dry protective dressing every evening. Observations on consecutive days revealed the absence of the dressing, and the resident confirmed that the dressing was changed infrequently. The Director of Nurses acknowledged that staff should be completing physician's orders. Another resident was observed without a boot immobilizer, which was supposed to be worn at all times except during hygiene and exercises, according to an orthopedic consult. However, there was no physician order for the boot immobilizer in the resident's records. Interviews with nursing staff and management confirmed the absence of a necessary order for the boot immobilizer, indicating a lapse in obtaining and documenting physician orders. Additionally, the facility failed to obtain weekly weights for two residents as per physician orders. One resident's records showed missed weight documentation on several occasions, and there was no indication of refusal by the resident. Similarly, another resident's records indicated signed-off weights without actual documentation, despite a noted weight loss over six weeks. The Director of Nurses confirmed that nursing staff should be following physician orders and documenting weights in the electronic medical record.
Failure to Monitor and Report Significant Weight Gain
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with liver cirrhosis. The resident was admitted with diagnoses including chronic kidney disease, cirrhosis, and edema, and had physician orders for daily weights due to the risk of significant weight gain. Despite these orders, the facility did not obtain daily weights on several days and failed to notify a physician or nurse practitioner of a significant weight gain of 12.2 lbs over four days. The resident's weight was not recorded on three consecutive days, and there was no documentation of the resident refusing to be weighed or any attempts to re-weigh the resident to confirm the weight gain. The nurse practitioner, who examined the resident, was not informed of the potential significant weight gain or the resident's refusal to be weighed. The facility's policy required that any weight change of 5% or more be confirmed and reported to the dietitian, but this was not done. The medical record lacked evidence of practitioner notification regarding the weight gain, and the weight was only confirmed after the surveyor's interview. The Director of Nurses acknowledged that the weight should have been confirmed and reported as per the physician's orders.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement necessary interventions for pressure ulcer care for Resident #119, who was admitted with severe cognitive impairment, dementia, severe protein malnutrition, and failure to thrive. The resident was assessed as being at risk for skin breakdown and had two unstageable pressure ulcers. The care plan for Resident #119 included the use of an air mattress and Prevalon boots to prevent further skin breakdown and aid in healing. However, observations over several days revealed that the resident was on a standard mattress without the prescribed air mattress, and there were no Prevalon boots in the room. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the interventions outlined in the care plan were not being followed. The CNA and nurse were unaware of the requirement for an air mattress and Prevalon boots, and the unit manager acknowledged that these interventions should have been provided. The Director of Nursing also confirmed that the interventions in the care plan should have been implemented to support wound healing for Resident #119.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident who experienced significant weight loss. The resident, admitted with diagnoses including major depressive disorder, asthma, and muscle weakness, showed a weight loss of 7.25% over one month. Despite the facility's policy requiring immediate notification to the dietitian for any weight change of 5% or more, the resident was not assessed by the dietitian for further interventions. The last dietitian assessment was conducted months prior, and no recent progress notes were available. Interviews revealed a lack of communication and awareness among staff regarding the resident's weight loss. The dietitian, new to the facility, was unsure if she had been informed about the resident's condition, while the Director of Nursing was under the impression that the resident was gaining weight. This miscommunication and oversight resulted in the resident not receiving timely dietary interventions, as required by the facility's policy.
Deficiencies in PICC Line Care and Maintenance
Penalty
Summary
The facility failed to provide proper care and maintenance of Peripherally Inserted Central Catheters (PICC) for two residents, leading to deficiencies in the administration of intravenous therapy. For one resident, the facility did not change the PICC line dressing as ordered, and the dressing was obscured by gauze, preventing visualization of the insertion site. The nurse responsible for the dressing change did not obtain measurements and used gauze under the transparent dressing, which was against the facility's policy. The Unit Manager and Director of Nursing confirmed that the dressing should not have gauze underneath and should allow for visualization of the insertion site. For the second resident, the facility failed to change or reinforce a PICC line dressing that was lifting at the edge, compromising its integrity. The dressing was observed to be lifting on multiple occasions, and the insertion site was not visible due to a medicated patch. Although the Medication Administration Record indicated that the dressing was changed, observations showed it was not. The LPN involved stated that he did not change the dressing and would notify a Registered Nurse if a dressing was lifting, as he was not authorized to change PICC line dressings. The Director of Nursing acknowledged that a lifting PICC line dressing should be changed or reinforced and that the facility's policy is to change the dressing weekly. The report highlights the failure to adhere to professional standards of practice for PICC line care, as evidenced by the lack of proper dressing changes and documentation discrepancies.
Medication Error Due to Duplicate Vancomycin Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was cognitively intact and admitted with diagnoses including enterocolitis due to clostridium difficile, was prescribed Vancomycin to be administered twice daily for seven days, followed by once daily for another seven days. However, due to an insurance issue, the original Vancomycin HCl Oral Suspension was not covered, and a new order for Firvanq Oral Solution was obtained. This resulted in both medications being administered concurrently, leading to the resident receiving Vancomycin four times daily instead of the prescribed two times daily. The error was identified through a review of the resident's Medication Administration Record and confirmed through interviews with nursing staff and the Nurse Practitioner. The Unit Manager acknowledged that the nurse should have discontinued the original Vancomycin order when the new Firvanq order was placed. The Director of Nursing confirmed that administering Vancomycin four times daily constituted a medication error, as the resident was only supposed to receive it twice daily.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to proper food handling practices, increasing the risk of foodborne illness. During a lunch tray line service, the Foodservice Director (FSD) was observed wearing gloves while making a sandwich. After removing her gloves, she touched the lid of a garbage can with her bare hands, contaminating them. She then handled multiple resident meal trays with these contaminated hands. The FSD continued to touch various surfaces, including the handle of a walk-in refrigerator and a cup placed on a resident's tray, without washing her hands. It was only after retrieving food from the oven that the FSD washed her hands. In an interview, the FSD acknowledged the need for handwashing when leaving stations, changing gloves, and after contamination, but admitted she failed to do so during the observed incident.
Inadequate Disinfection of Shared Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Nurse #6 and Nurse #9. During a medication pass, Nurse #6 was observed using a blood pressure cuff and a fingertip pulse oximeter on three different residents without disinfecting the equipment between uses. Nurse #6 admitted to cleaning the vital signs machine only at the end of her shift, contrary to the facility's policy and CDC recommendations, which require disinfection between each resident use. Unit Manager #1 confirmed that Nurse #6 should have cleaned the equipment between each resident. Similarly, Nurse #9 was observed checking a resident's blood pressure with a portable cuff without sanitizing it before or after use. The Director of Nursing confirmed that the nursing staff is expected to clean the vital sign machine between each resident. These observations indicate a failure to adhere to the facility's policy and CDC guidelines for disinfection of non-critical resident-care items, potentially increasing the risk of communicable disease transmission.
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.
