Brigham Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburyport, Massachusetts.
- Location
- 77 High Street, Newburyport, Massachusetts 01950
- CMS Provider Number
- 225549
- Inspections on file
- 25
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Brigham Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician, health care agent, and administrative staff as required by policy. The nurse did not document the incident or inform the oncoming shift, leading to a delay in addressing the resident's injuries, which were later diagnosed as fractures. The DON was only informed after the family reported the fall.
A resident experienced an unwitnessed fall and was found on the floor by a nurse and CNA. The nurse did not document the fall, perform a thorough assessment, or notify the next shift, contrary to facility policy. The resident later complained of pain and was diagnosed with fractures at the hospital. The DON confirmed the nurse's failure to follow procedures.
The facility did not conduct, review, or document an annual facility-wide assessment to determine necessary resources for resident care during regular operations and emergencies. Despite policy requirements, the surveyor found that the facility could not provide a current assessment. Administrator #2, responsible for the assessment, admitted to not completing it and lacked access to previous assessments. The Director of Operations confirmed the oversight, leading to a deficiency.
The facility failed to provide a homelike dining experience, as residents were served meals using Styrofoam cups and bowls, plastic cutlery, and trays. This practice was due to staffing issues in the kitchen, preventing the use of regular dishes. Residents expressed dissatisfaction, and staff acknowledged the inappropriate use of disposable items.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. One resident lacked a fall care plan intervention, while another did not have personalized mood and behavior care plans. A third resident's care plan was incomplete for dialysis and antidepressant medication, and another resident's care plan lacked details on psychotropic medication use. Staff interviews revealed communication and implementation issues.
A facility failed to develop a care plan and ensure proper communication for a resident requiring dialysis. The resident, with end-stage kidney disease and moderately impaired cognition, lacked a documented physician's order for hemodialysis. The dialysis communication book, crucial for facility-dialysis center communication, was incomplete and not with the resident during sessions. Staff were unaware of the resident's dialysis access type, and there was no order to monitor the CVC site for infection.
The facility failed to maintain sufficient CNA staffing on weekends, leading to delays in resident care. Staffing records and interviews revealed that the facility was below the necessary CNA levels for multiple weekend shifts from April to September 2024. Despite efforts to hire more staff and change staffing agencies, challenges in maintaining adequate staffing persisted.
The facility failed to provide necessary substance abuse services for residents with a history of substance use disorder. A resident with a history of heroin and alcohol use was not offered AA/NA services despite expressing a desire to continue these meetings. Additionally, six other residents with similar histories were also not offered these services, contrary to the facility's policy.
The facility failed to ensure timely physician acknowledgment of pharmacist recommendations for two residents. One resident had an Ativan dose exceeding recommended levels without physician clarification, while another had a Zetia prescription without a documented diagnosis clarification. The Director of Nursing could not locate the relevant MMRs or physician responses, highlighting a lapse in communication and documentation.
The facility failed to secure medication rooms on two units, leaving them open and unattended, contrary to policy. A nurse admitted to leaving a medication room open after retrieving masks, acknowledging it was a mistake.
The facility did not maintain a current CLIA certificate, which expired and was not renewed, affecting the ability to perform necessary tests for residents requiring blood glucose monitoring. Additionally, a resident with dementia and other conditions did not have a required albumin level test performed, as the nursing staff failed to notify the lab service provider.
The facility failed to maintain adequate staffing in its dietary services, as observed by surveyors and reported by staff and residents. The facility assessment required three staff per shift, but observations showed only two staff were present on multiple occasions. A resident noted that meals were served on styrofoam dishes due to a lack of staff to wash dishes. The absence of a Food Service Director further exacerbated the staffing issues.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and unmet dietary needs. Residents reported receiving incorrect meal trays, missing preferred items, and not being involved in menu selection. Staff interviews revealed systemic issues with menu selection and communication between the kitchen and residents.
The facility failed to provide a nourishing evening snack when there was more than 14 hours between dinner and breakfast. The final food tray for the evening meal was passed at 5:25 P.M., and breakfast started at 7:30 A.M. the following day, resulting in a 14-hour and 45-minute gap. Residents reported limited snack options, and staff interviews confirmed that snacks were not consistently available. The Food Service Director and Dietician acknowledged the need for compliance with the policy, and the Administrator stated that meals should be served after 5:00 P.M. with substantial evening snacks available.
The facility failed to store food according to professional standards, with surveyors observing unlabeled and undated items in the refrigerator, freezer, and dry storage. Items were improperly stored, including food placed directly on the floor and open bags in the freezer. Dietary staff confirmed these practices were against policy.
The facility failed to maintain accurate medical records for four residents, including missing weight documentation for two residents, incorrect BiPAP usage records for another, and incomplete CNA service documentation. A resident's weights were not recorded in the EHR, and a broken BiPAP was falsely documented as in use. CNAs reported insufficient time for documentation due to workload, and a resident's weights were struck out in error without reweighing.
A resident with moderately impaired cognition and total dependence on staff for personal hygiene was observed with unwanted chin hair, which they expressed a desire to have removed. Despite the facility's policy on maintaining resident dignity, a CNA admitted to not having time to assist with the grooming, leading to a deficiency in care.
The facility failed to issue transfer notices and notify the Ombudsman for two residents transferred to the hospital. One resident with dementia was transferred due to low hematocrit and hemoglobin levels, while another resident with heart failure was transferred following a fall and admitted for hypokalemia and congestive heart failure. The facility did not document the required notifications.
The facility failed to provide a bed hold policy to two residents before hospital transfers. One resident with dementia was transferred due to low hematocrit and hemoglobin levels, while another cognitively intact resident was transferred after a fall and diagnosis of hypokalemia and heart failure. The facility did not issue the required bed hold policy to either resident or their representatives.
A facility failed to complete a timely PASRR for a resident with SMI after their stay exceeded the 30-day exemption period. The resident was admitted with bipolar disorder and depression, and although initially screened, a subsequent Level I Screening was not submitted as required. The Admissions Liaison and Social Worker indicated a lack of responsibility and access to the PASRR portal, and the Administrator was unaware of the oversight.
The facility failed to create baseline care plans within 48 hours of admission for three residents, including one with end-stage kidney disease and another with PTSD and diabetes. The absence of these plans, which are crucial for effective and person-centered care, was confirmed by nursing staff and the Director of Nursing.
The facility failed to review and revise comprehensive care plans for two residents following assessments. One resident's care plan was not updated to reflect a change in advanced directives to DNR, and another resident's care plan lacked specific details about high-risk medication use. Staffing issues and lack of coordination contributed to these deficiencies.
A resident with severe cognitive impairment was found to have an air mattress set incorrectly, contrary to the physician's orders. The physician had specified a setting of 130, but observations showed it was set to 150. Interviews with staff revealed a lack of adherence to the physician's orders and manufacturer guidelines, despite the facility's policy requiring compliance with such orders.
A resident with limited range of motion in the left hand did not receive appropriate care as the facility failed to implement a splint-wearing schedule. Despite recommendations from the occupational therapist, nursing staff were unaware of the requirement, and the resident was observed multiple times without the prescribed splint. This indicates a lack of communication and documentation regarding the resident's care plan.
A facility failed to document the size of a resident's indwelling urinary catheter in the physician's orders, leading to a deficiency in care. The resident, admitted with urine retention, experienced discomfort and discharge, prompting catheter irrigation. The omission was confirmed through record reviews and staff interviews, with the catheter size eventually identified as 16 French with a 10-milliliter balloon.
A resident with severe cognitive impairment and significant weight loss did not receive prescribed fortified foods and nutritional supplements. Despite physician orders and care plans, the resident's meal trays consistently lacked fortified items such as shakes, juices, and yogurt. Staff interviews confirmed the absence of these items, contributing to the resident's continued weight loss.
A facility failed to follow professional standards for enteral feeding administration for a resident with dysphagia and hemiplegia. The resident's Jevity 1.2 bottle, dated several days prior, was used beyond the manufacturer's recommended hang time. Staff interviews revealed that the nursing staff did not change the bottle daily as required, leading to the deficiency.
The facility failed to provide necessary respiratory care for two residents. One resident's BiPAP machine was broken and not repaired, despite staff awareness and a physician's order for its use. Another resident received oxygen at a higher rate than prescribed, with staff unaware of the correct settings. These deficiencies highlight a lack of adherence to care plans and physician's orders.
A facility failed to develop a comprehensive trauma-informed care plan for a resident with PTSD. The care plan lacked specific triggers and interventions, contrary to the facility's policy. Interviews with the DON and MDS Nurse confirmed the deficiency, highlighting the need for resident-specific care plans.
A facility failed to specify the duration for a PRN antipsychotic medication prescribed to a resident with borderline personality disorder and other conditions. The facility's policy requires PRN psychotropic drugs to have a limited duration, typically 14 days, unless extended with documented rationale. Despite a recommendation from the Psychiatric Nurse Practitioner to discontinue the PRN Zyprexa, the facility did not address this within the expected timeframe, resulting in a deficiency.
A resident with dysphagia and hemiplegia was not provided with the physician-ordered therapeutic diet. Despite orders for a regular diet with dysphagia advanced texture and thin liquids, the resident received a meal that did not meet these specifications. Dietary staff were preparing meals based on memory due to a recent change in food vendors and lack of updated diet breakdowns. The facility's dietary department failed to adhere to the prescribed diet, as confirmed by the Food Service Director and other staff.
A resident with severe cognitive impairment and dysphagia was not consistently provided with a lip plate during meals, despite a physician's order and facility policy requiring it. Observations showed the resident was served breakfast without the necessary adaptive equipment, and staff interviews confirmed the kitchen's responsibility to supply it.
The facility did not notify the State Agency of a change in its Administrator. Administrator #2 was noted as the current Administrator as of June 21, 2024, but Administrator #1 began on September 9, 2024, without the State Agency being informed. Administrator #2 confirmed her last day was September 6, 2024, and the Chief Nursing Officer admitted the oversight.
The facility did not provide accurate estimated costs on Advanced Beneficiary Notices (ABNs) for two residents who transitioned off Medicare Part-A benefits. The ABNs lacked a detailed cost breakdown, which is essential for informing residents of their potential financial liabilities for services not covered by Medicare. Interviews with the Business Office Manager and Administrator confirmed the omission.
A facility failed to encode and transmit a Minimum Data Set (MDS) discharge assessment for a resident in a timely manner. The resident, admitted with pancreatitis and skin cancer, was discharged home, but the required MDS discharge assessment was not completed within the mandated 14 days. Interviews with the DON and MDS Nurse confirmed the oversight.
The facility inaccurately coded the MDS for two residents, leading to deficiencies in their assessments. One resident's MDS incorrectly indicated the use of anticoagulant and antiplatelet medications, while another resident's discharge location was wrongly coded. These errors were confirmed by the MDS Nurse and reflect a failure in ensuring accurate resident assessments.
The facility failed to post daily nurse staffing information as required by its policy. Observations on multiple days showed the absence of this information in the reception area. The Scheduler admitted to not posting the information on certain days, including weekends, due to lack of assigned responsibility. The DON confirmed the requirement for daily posting, indicating a lapse in compliance.
The facility failed to ensure that the kitchen staff consistently followed the established weekly menu for resident meals. Observations revealed that meals served did not match the planned menu, with missing ingredients and unplanned substitutions. Staff interviews indicated issues with a cook not adhering to the menu, leading to deviations. A resident reported being served random food not on the menu and often having no alternate meal choice.
The facility failed to serve food and beverages at safe and appetizing temperatures, as required by their policies. A test tray observation revealed that food items were not within acceptable temperature ranges, with a cold tuna sandwich served at 69.1°F and mixed vegetables at 106.9°F. The facility's records showed inconsistent measurement and recording of food temperatures, and residents expressed dissatisfaction with the food quality. Staff admitted to not measuring food temperatures due to being too busy, and there was insufficient food prepared for test trays.
The Facility failed to maintain accurate medical records for two residents, as weekly skin assessments were not consistently documented. One resident's records lacked documentation for several weeks, while another's records showed scheduled checks marked as completed without corresponding assessment forms. The DON confirmed the requirement for weekly documentation.
A resident under hospice care passed away, but the facility failed to notify the Health Care Agent (HCA) and Hospice Agency in a timely manner. The delay occurred because the former DON did not promptly pronounce the death, and the LPN on duty was unable to do so. The HCA and Hospice Agency were informed approximately eight hours later when a family member arrived at the facility.
A resident with multiple diagnoses was observed with dirty and soiled sneakers, which were not cleaned by the nursing staff. Interviews revealed that the resident often had food stains on clothing that were not promptly addressed, and the DON confirmed this was a dignity issue.
A resident's wheelchair was found with dried food caked on it, and it had not been cleaned for approximately six weeks. Staff confirmed that the cleaning schedule was not followed consistently, and the wheelchair's condition prevented its proper use during meals. The Housekeeping Director and DON acknowledged the lapse in maintaining a clean environment.
A resident experienced a significant change in condition, including chest pain and elevated blood pressure. Nurse #1 failed to assess the emergency timely, did not call 911 immediately, and did not administer prescribed medication. The resident was transferred to the hospital over two hours later and died of septic shock and pneumonia.
The facility failed to ensure that nursing staff had the appropriate competencies to respond to a significant change in condition for a resident. The resident presented with chest pain, elevated blood pressure and pulse, and other symptoms, but EMS was not alerted for over two hours. The resident was eventually sent to the hospital and died there.
The facility failed to ensure that open medications were dated as required on two out of four sampled medication carts. Observations included undated and expired medications such as Fluticasone Propionate Nasal Spray, Albuterol inhaler, Carbamide Peroxide Ear Drops, Sodium Bicarb, Banophen Allergy Capsules, and Fiber Therapy Psyllium Husk. Interviews with staff confirmed that medications need to be dated when opened and expired medications should be discarded.
The facility failed to maintain accurate medical records for four residents, leading to discrepancies between documented care and observed care. Residents were observed not receiving treatments as per physician orders, and the Treatment Administration Records inaccurately indicated that the treatments were completed. Interviews with nursing staff confirmed the discrepancies.
The facility failed to implement adequate infection prevention and control practices. Nurses did not perform proper hand hygiene during a dressing change, used bare hands to handle medication, and failed to disinfect shared medical equipment between resident uses. The DON confirmed the correct procedures were not followed.
The facility failed to update the care plan for a cognitively impaired resident who was observed chewing non-food items. Despite nursing notes indicating the behavior, the care plan lacked interventions, and staff did not consistently prevent access to paper products, leading to a deficiency.
The facility failed to follow physician's orders for two residents. One resident did not have prescribed tubi grips or TED stockings applied, and another resident, at risk for pressure ulcers, was not positioned with heels floated as required. Staff interviews confirmed these lapses.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to adhere to its policies regarding the notification of changes and fall prevention for a resident who experienced an unwitnessed fall during the overnight shift. The resident, who had a medical history including congestive heart failure and muscle weakness, was found sitting on the floor by a nurse and a CNA. Despite the facility's policy requiring immediate notification of the resident's physician, health care agent, and administrative staff in such incidents, the nurse did not report the fall to any of these parties. The nurse, who was aware of the facility's policies, assessed the resident and found no immediate signs of injury. However, the nurse did not document the incident, notify the oncoming shift nurse, or complete an incident report. The resident later complained of back pain, leading to a hospital transfer where fractures were diagnosed. The lack of documentation and communication resulted in a delay in addressing the resident's injuries. The Director of Nurses was not informed of the fall until the resident's family reported it the following day. An investigation revealed that the nurse had not followed the required procedures, including documenting the incident and notifying relevant parties. The nurse later admitted to forgetting to report and document the fall, which was only addressed after the DON initiated an investigation.
Failure to Document and Assess After Resident Fall
Penalty
Summary
The facility failed to provide nursing care and treatment that met professional standards of quality for a resident who experienced an unwitnessed fall. During the overnight shift, the resident was found sitting on the floor by a nurse and a CNA after a fall. Although the nurse claimed to have assessed the resident before moving them, there was no documentation to support that an adequate assessment was conducted for potential injuries. The following day, the resident complained of pain and was diagnosed with fractures after being transferred to the hospital. The facility's policies required a comprehensive post-fall assessment, documentation, and notification of the physician and family, none of which were completed by the nurse on duty. The nurse did not document the fall, perform neurological checks, or report the incident to the next shift. The nurse was aware of the facility's policies but failed to adhere to them, resulting in a lack of immediate and appropriate care for the resident. The Director of Nursing was not informed of the fall until the resident's family raised concerns the next day. Upon assessment, the resident was found to be in pain and was subsequently sent to the hospital. The DON confirmed that the nurse did not follow the facility's procedures and policies, which included assessing the resident for injuries, documenting the incident, and notifying the appropriate parties.
Failure to Conduct Annual Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct, review, and document a facility-wide assessment annually to determine the necessary resources for competent resident care during both regular operations and emergencies. The facility's policy, dated 3/4/24, mandates an annual assessment to establish responsibilities and procedures for the assessment process. However, during a survey, the facility was unable to provide a current assessment. The surveyor requested the assessment on two occasions, but Administrator #1 could only provide an outdated version and was unable to locate any other assessments. Administrator #2, who had been employed for about 10 weeks, admitted to not conducting the required assessment review and lacked access to previous assessments. The Director of Operations acknowledged that Administrator #2 was responsible for updating the assessment but failed to do so. The facility's policy requires the assessment to be updated annually and whenever there are significant changes, but this was not adhered to, resulting in a deficiency.
Failure to Provide Homelike Dining Experience
Penalty
Summary
The facility failed to ensure a homelike dining experience for residents on two units, as observed by surveyors. During multiple observations, residents were served meals using Styrofoam cups and bowls, plastic cutlery, and trays, which did not align with the facility's policy of promoting and maintaining resident dignity during mealtimes. The use of disposable items was consistent across both breakfast and lunch services on different days, affecting all observed residents in the dining areas. Interviews with residents and staff revealed dissatisfaction with the use of Styrofoam and plastic items, with residents expressing a desire for meals to be served on actual dishes rather than trays. Staff interviews indicated that the use of disposable items was due to staffing issues in the kitchen, which prevented the washing of regular dishes. The Food Service Director and the facility Administrator acknowledged that the use of paper and Styrofoam products was not appropriate and that meals should not be served on trays in the dining rooms.
Deficiencies in Comprehensive Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in their care. For one resident, the facility did not implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. Observations showed that the fall mat was not properly positioned, and the urinal was not visible in the resident's room. Interviews with staff revealed inconsistencies in the communication and implementation of care plan interventions, with some staff unaware of the need for fall mats or the urinal. Another resident with a history of borderline personality disorder, suicidal ideations, major depression disorder, and opioid abuse did not have personalized mood, behavior, and substance abuse care plans. The resident's care plan failed to address their history of homicidal ideation, opiate and marijuana abuse, and feces smearing behavior. Interviews with the social worker confirmed the need for personalized care plans to address these issues. Additionally, a resident with end-stage kidney disease did not have a comprehensive care plan for dialysis and antidepressant medication. The care plan lacked details on dialysis schedules and care for the dialysis access site. Another resident with PTSD and hemiplegia did not have a care plan for psychotropic medication use, missing specific medication details and potential side effects. Interviews with the Director of Nursing confirmed the absence of these critical care plan components.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to develop a comprehensive plan of care for a resident requiring dialysis and did not ensure proper communication between the nursing facility and the dialysis center. The resident, who was admitted with end-stage kidney disease, pneumonia, and a fracture, had moderately impaired cognition and required moderate assistance with daily activities. Despite these needs, the facility did not have a physician's order for hemodialysis documented in the resident's records for September 2024. Additionally, the dialysis communication book, which is essential for conveying needs, changes, and concerns between the facility and the dialysis center, contained only three dated communication forms out of a possible twelve. On the day of the survey, it was observed that the dialysis communication book was not with the resident as required, indicating a lapse in the communication process. Nurse #4 acknowledged that the book should accompany the resident to dialysis sessions, which occur three times a week. Furthermore, Nurse #4 was unaware of the type of dialysis access the resident had, while Nurse #6 later confirmed the resident had a Central Venous Catheter (CVC) for dialysis access. Nurse #6 also noted the absence of a physician's order to monitor the CVC site for infection and drainage, highlighting a significant oversight in the resident's care plan.
Facility Fails to Maintain Adequate Weekend CNA Staffing
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being, particularly on weekends. The deficiency was identified through a review of staffing records and interviews with residents and staff. Residents expressed concerns about the lack of certified nurse assistants (CNAs), leading to delays in responding to call lights. The Chief Nursing Officer (CNO) confirmed that the facility did not have a formal assessment of staffing needs, but provided a list of necessary staffing levels, which were not met on multiple occasions. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for fiscal year Quarter 3, 2024, indicated excessively low weekend staffing. The facility's weekend staff schedules from April to June 2024 showed that the facility was below the determined minimum CNA staffing levels for 20 weekend shifts. This issue persisted into the next quarter, with 16 additional weekend shifts lacking sufficient CNA staff. Interviews with CNAs and nurses revealed that the staffing shortages were particularly severe during April to June 2024, and although there were improvements after changing staffing agencies, challenges remained. The Director of Nursing (DON) acknowledged the staffing deficiencies during the specified quarter and noted efforts to hire more staff and change staffing agencies. Despite these efforts, the facility continued to struggle with maintaining adequate CNA staffing levels. The scheduler confirmed that the staffing ratios provided by the CNO were accurate and that the facility had difficulty replacing call-outs or finding enough CNAs to meet the minimum staffing requirements.
Failure to Provide Substance Abuse Services
Penalty
Summary
The facility failed to provide necessary substance abuse services for residents with a history of substance use disorder. Specifically, Resident #47, who was admitted with diagnoses including bipolar disorder, PTSD, and borderline personality disorder, was not offered Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) services despite having a history of heroin and alcohol use. The resident expressed a desire to continue participating in AA/NA meetings, which they had attended in the community prior to admission, but reported that no such services were offered by the facility until the day of the interview. Additionally, the facility's social worker identified six other residents with histories of alcohol, narcotics, and marijuana use who also had not been offered AA/NA services. The facility's policy on 'Safety for Residents with Substance Abuse Disorder' indicates that efforts should be made to prevent substance use, including providing treatment services such as behavioral health services and AA/NA meetings. However, the facility did not adhere to this policy, resulting in a deficiency in providing necessary behavioral health care and services to residents with substance use disorders.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two residents. Resident #33, who was admitted with diagnoses including dementia and anxiety, had a doctor's order for Ativan 5 mg PRN, which exceeded the recommended initial dose for the elderly. The MMR requested clarification of the Ativan dose, but the medical record did not indicate that the doctor was made aware of this recommendation or that a response was provided. Resident #47, admitted with diagnoses including PTSD, hemiplegia, and diabetes, had a doctor's order for Zetia 10 mg for diabetes. The MMR requested clarification of the diagnosis for the use of Zetia, but there was no documentation of the physician's response. During an interview, the Director of Nursing stated that the pharmacist reviewed all residents on the specified date but was unable to locate any of the MMRs or physician responses, indicating a lapse in communication and documentation processes.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, the medication rooms on both the first and second floors were observed to be open and unattended by staff. On two separate occasions, the surveyor noted that the medication rooms were left open without any staff present within eyesight, which is contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments with access limited to authorized personnel. During an interview, a nurse admitted to leaving the medication room open after retrieving masks, acknowledging it was a mistake and that the door should never be left open.
Failure to Maintain CLIA Certificate and Obtain Required Lab Test
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. During the survey, it was discovered that the facility's CLIA certificate had expired, and the payment for renewal was overdue. The Administrator acknowledged the lapse, and the Regional Nurse confirmed that the certificate should have been renewed, especially since there were seven residents requiring blood glucose monitoring, which necessitates a valid CLIA certificate. Additionally, the facility failed to obtain a necessary laboratory test for a resident. The resident, who was admitted with diagnoses including dementia, dysphagia, and osteoarthritis, had a physician's order to check an albumin level on the next lab day. However, the results were not found in the resident's electronic or paper medical records. The Director of Nursing and the Regional Nurse confirmed that the albumin level was not obtained as required, and the nursing staff failed to notify the laboratory service provider to perform the test.
Insufficient Staffing in Dietary Services
Penalty
Summary
The facility failed to provide sufficient staff to effectively carry out the functions of the food and nutrition services, as observed and reported by both staff and residents. The facility assessment indicated a requirement of 270 hours for dietary services, yet observations on multiple occasions showed that the kitchen was understaffed. On several days, only two staff members were present instead of the required three, as confirmed by interviews with dietary staff and the Food Services Director. The absence of a Food Service Director further compounded the staffing issues, as the newly hired director was still in orientation. During a Resident Council meeting, a resident reported that due to insufficient staff, meals were served on styrofoam dishes because there were not enough personnel to wash dishes. Interviews with the Regional Nurse and the Administrator confirmed that the kitchen should be staffed with three individuals per shift, including two dietary staff and one cook. The Administrator also clarified that the facility assessment hours were divided into 120 hours for cooks and 150 hours for dietary staff, excluding the Food Services Director's 40 hours.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and unmet dietary needs. Resident #17, who has severe cognitive impairment and requires a mechanically altered diet, was repeatedly served eggs despite having a documented dislike for them. Staff interviews confirmed that the resident's preferences were known but not honored, and the kitchen staff failed to follow the diet slip instructions. Resident #14, who is cognitively intact, expressed frustration over consistently receiving incorrect meal trays. Despite multiple complaints, the resident's preferences for breakfast items like oatmeal and coffee were not met, and the resident was served disliked items such as eggs. The resident also reported not being involved in menu planning and not receiving alternative meal options when requested. Resident #2, also cognitively intact, did not receive requested items like bananas and yogurt, which were important for their dietary needs. The resident was served ham, a disliked item, and expressed concern over the lack of menu selection opportunities. Similarly, Resident #10 reported consistently receiving incorrect meal trays, missing items like bananas and yogurt, and not being involved in menu selection. Staff interviews revealed systemic issues with menu selection and communication between the kitchen and residents, leading to unmet food preferences.
Failure to Provide Nourishing Evening Snacks
Penalty
Summary
The facility failed to provide a nourishing evening snack when there was more than 14 hours between dinner and breakfast, as observed by surveyors. The facility's policy requires that no more than 14 hours should elapse between the evening meal and breakfast unless a nourishing snack is provided at bedtime. However, the surveyor noted that the final food tray for the evening meal was passed at 5:25 P.M., and breakfast started at 7:30 A.M. the following day, resulting in a 14-hour and 45-minute gap. Residents reported that they sometimes received an evening snack upon request, but there were limited options, and certain items like sandwiches and peanut butter were unavailable. Interviews with staff and residents revealed that the snack options were insufficient and not consistently available. Residents expressed dissatisfaction with the lack of snack choices, and the Food Service Director acknowledged the need to adjust meal times to comply with the policy. The Dietician confirmed that substantial evening snacks should be available when the time between dinner and breakfast exceeds 14 hours. The Administrator also stated that meals should be served after 5:00 P.M., and substantial evening snacks should be available on the units.
Deficiencies in Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage, as observed by surveyors. In the refrigerator, several items such as heads of lettuce, tomatoes, cabbages, and various leftovers were found without labels or dates. Additionally, a water jug with sliced lemons was also not labeled or dated. These items were improperly stored, with some placed directly on shelves or on top of other containers, contrary to the facility's policy that requires labeling with the delivery date and proper storage. In the dry food storage area, multiple food items, including packs of ginger ale, boxes of frozen bread, dinner rolls, canned goods, and ground coffee, were found stored directly on the floor, violating the policy that mandates storage at least six inches off the ground. In the freezer, open bags of frozen French toast, steak fries, and cookie dough were also found without labels or dates. Dietary staff acknowledged these deficiencies, noting that unlabeled and undated food should be discarded, and that food should not be stored on the floor or left in open bags.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, leading to several deficiencies. For Resident #22, the facility did not document weights in the Electronic Health Record (EHR) as required by the physician's order. Although the Certified Nurse Assistant (CNA) reported the weights verbally to the nurse, there was no documentation in the EHR, which was confirmed by interviews with the CNA, Nurse #2, and the Regional Nurse. Resident #2's medical record inaccurately documented the use of a BiPAP machine, which was broken and not in use. Despite the resident's report of the broken BiPAP and the nurse's acknowledgment of the issue, the Treatment Administration Record (TAR) falsely indicated that the BiPAP was implemented on several shifts. The Director of Nursing (DON) was aware of the broken BiPAP but did not ensure the plan of care was updated or changed. For Resident #28, the facility failed to document services provided by CNAs for the majority of shifts in August 2024. The Director of Nursing confirmed the expectation for CNAs to document services each shift, but CNA #3 reported insufficient time to complete documentation due to workload. Additionally, Resident #23's weights were not documented in the medical record, and several weights were struck out in error without reweighing the resident. The Dietician confirmed the lack of documented weights since admission, despite the resident's history of refusing weights.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity by not providing assistance with the removal of unwanted chin hair. The resident, who was admitted in March 2021 with diagnoses including heart disease, kidney disease, and depression, expressed a desire to have the chin hair removed. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and was totally dependent on staff for personal hygiene. Despite this, the section of the MDS indicating how the resident completes personal hygiene was left blank, and the care plan did not indicate any refusal of care by the resident. Observations by the surveyor on multiple occasions revealed that the resident had chin hair approximately 1 inch long. During an interview, the resident confirmed their dislike for the chin hair and their wish for it to be removed. A Certified Nurse Aide (CNA) acknowledged that it was the responsibility of CNAs to remove chin hair but admitted to not having time to do so for the resident. The facility's policy on promoting and maintaining resident dignity emphasizes grooming according to resident preference, which was not adhered to in this case.
Failure to Notify Ombudsman and Issue Transfer Notices
Penalty
Summary
The facility failed to provide a notice of transfer and failed to send a copy of the notice to the Ombudsman for one resident, and failed to send a copy of the transfer notice to the Ombudsman for another resident. Resident #30, who was admitted with diagnoses including dementia, was transferred to the hospital due to critically low hematocrit and hemoglobin levels. The resident had been non-compliant with transfusion and lab draws, and expressed feeling weak, prompting the transfer. However, the facility did not issue a transfer notice to the resident or send a copy to the Ombudsman. Resident #22, admitted with diagnoses including heart failure and pulmonary hypertension, was transferred to the hospital following a fall and was later admitted for hypokalemia and congestive heart failure. The facility failed to document that the Ombudsman was notified of this transfer. Interviews with the Regional Nurse and the Director of Nurses confirmed the lack of transfer notices and notifications to the Ombudsman for both residents.
Failure to Provide Bed Hold Policy Before Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to two residents or their representatives before they were transferred to the hospital, which is a requirement according to the facility's policy. Resident #30, who was admitted with diagnoses including dementia and had impaired cognition, was transferred to the hospital due to critically low hematocrit and hemoglobin levels. Despite the emergency nature of the transfer, the facility did not issue a bed hold policy to the resident or their representative prior to the transfer. This was confirmed during an interview with the Regional Nurse and the Director of Nurses, who acknowledged the oversight. Similarly, Resident #22, who was cognitively intact and admitted with conditions such as heart failure and pulmonary hypertension, was transferred to the hospital following a fall and subsequent diagnosis of hypokalemia and congestive heart failure. The surveyor's review of the resident's medical records revealed no documentation of a bed hold policy being provided. The Regional Nurse was unable to locate any such documentation, confirming that the policy was not issued as required.
Failure to Complete Timely PASRR for Resident with SMI
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) in a timely manner for a resident with serious mental illness (SMI) after their stay exceeded the 30-day exemption period. The resident was admitted with diagnoses including bipolar disorder and depression, and initially had a positive SMI screen. However, a Level II PASRR Evaluation was not indicated at the time due to an Exempted Hospital Discharge, which allows for a maximum stay of 30 days without further screening. The facility was required to submit a Level I Screening to the Department of Mental Health by the 25th day if the stay was expected to exceed 30 days, but this was not done. Interviews revealed that the Admissions Liaison was responsible for PASRR Level I screenings only upon admission and was unaware of who was responsible for subsequent screenings after the previous staff member resigned. The Social Worker, who was a consultant, stated that no one in the facility had access to the PASRR portal to complete the necessary screenings and had informed the Administrator multiple times without resolution. The Administrator was unaware that the PASRRs were not being completed as required.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #25, who was admitted with end-stage kidney disease, pneumonia, and a fracture, did not have a baseline care plan that included necessary instructions for dialysis treatment. The medical record lacked a doctor's order for hemodialysis, and there was no care plan addressing the monitoring of the Central Venous Catheter (CVC) for infection and drainage. Interviews with nursing staff confirmed the absence of a care plan and the expectation that such a plan should have been in place. Similarly, Resident #47, admitted with PTSD, hemiplegia, and diabetes, and Resident #49, admitted with a hip fracture and malnutrition, also did not have baseline care plans developed within the required timeframe. The Director of Nursing and nursing staff were unable to locate any baseline care plans for these residents in their medical records. The facility's policy on comprehensive care plans did not specify the need for a baseline care plan upon admission, contributing to the oversight.
Deficiencies in Comprehensive Care Plan Review and Revision
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team following the completion of comprehensive assessments. For one resident, the facility did not update the care plan to reflect a change in advanced directives from full code to do not resuscitate (DNR), despite a physician's order indicating the change. The care plan was overdue for review, and no care plan meeting was held to address this change. Interviews with staff revealed that the responsibility for updating care plans was unclear due to staffing issues, with the MDS nurse and social worker positions vacant or inadequately filled. For another resident, the facility did not review or revise the care plan to include specific details about high-risk medication use, such as the names of medications, associated diagnoses, or symptoms for use. The care plan was overdue for review, and the goals related to medication use were not specific or updated. The Director of Nursing acknowledged the lack of specific psychotropic medication use care plans and the overdue status of the care plan review. The facility's policies required that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, due to staffing challenges and lack of coordination, these requirements were not met, resulting in deficiencies in the care planning process for the residents involved.
Failure to Implement Physician's Orders for Air Mattress Settings
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident with severe cognitive impairment, as evidenced by a BIMS score of 2 out of 15. The deficiency involved the improper setting of an air mattress, which was not adjusted according to the physician's orders. The physician had ordered a low air loss mattress to be set at 130, with checks every shift to maintain this setting for monitoring and prevention purposes. However, observations by the surveyor revealed that the air mattress was consistently set to 150, which was not in accordance with the physician's orders. Interviews with facility staff, including a CNA and a nurse, indicated a lack of adherence to the physician's orders and manufacturer guidelines for the air mattress settings. The CNA stated that they do not adjust air mattress settings, while the nurse acknowledged the need to verify and implement the physician's order. The Regional Nurse also confirmed that nursing staff should follow the physician's orders and manufacturer's guidelines for air mattress settings. The facility's policy on the use of support surfaces emphasized the importance of using these devices in accordance with physician orders and manufacturer recommendations, which was not followed in this case.
Failure to Implement Splint Use for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary services and treatment for a resident who had a reduction in range of motion in the left hand. The facility's policy required that any resident with limited range of motion receive treatment to increase and maintain their range of motion. However, the facility did not implement a plan of care or a splint-wearing schedule for the resident, despite recommendations from the occupational therapist. The resident, who was admitted with diagnoses including dysphagia and hemiplegia following a cerebral infarction, was observed multiple times without the prescribed left-hand splint and palm protector. Certified nurse assistants and nurses were unaware of the requirement for the resident to wear the splint, indicating a lack of communication and documentation regarding the resident's care plan and physician's orders. The occupational therapist had completed training with the nursing staff and recommended the use of a left-hand splint with a palm protector for over 8 hours during the day. Despite this, the nursing staff did not obtain or implement the necessary physician's orders for the splint use, leading to the deficiency in care for the resident.
Failure to Document Catheter Size in Physician's Orders
Penalty
Summary
The facility failed to document the size of an indwelling urinary catheter in the physician's orders for a resident, leading to a deficiency in care. The resident, who was admitted with a diagnosis of urine retention, had an indwelling catheter in place. Despite the facility's policy to ensure appropriate catheter care, the physician's orders and the care plan did not specify the size of the Foley catheter and balloon. This omission was noted during a review of the resident's records and confirmed through interviews with nursing staff. Observations revealed that the resident experienced discomfort and a foul-smelling discharge, which prompted catheter irrigation and cleaning by the nursing staff. However, the lack of documentation regarding the catheter size was highlighted during an interview with a nurse, who acknowledged the importance of this information in preventing resident discomfort. The catheter size was eventually identified as 16 French with a 10-milliliter balloon, which the resident found comfortable. The regional nurse confirmed that catheter sizes should be documented in the physician's orders.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for Resident #19, who was admitted with diagnoses including dementia, dysphagia, and osteoarthritis. The resident, who had severe cognitive impairment and was dependent on staff for eating, experienced significant weight loss over several months. Despite physician orders and care plans indicating the need for fortified foods and nutritional supplements, these were not consistently provided. Observations on two separate days revealed that the resident's breakfast trays lacked the prescribed fortified items such as chocolate shakes, fortified juices, fortified milk, super cereal, and yogurt. Interviews with staff, including a CNA, nurse, dietary staff, and the dietitian, confirmed the absence of these fortified items on the resident's meal trays. The dietary staff admitted to not preparing or providing the necessary fortified foods, and the dietitian was unaware that the resident was not receiving the prescribed fortified shakes. The facility's failure to provide these nutritional interventions contributed to the resident's continued weight loss, as documented in the resident's electronic health record and dietary notes.
Failure to Adhere to Enteral Feeding Guidelines
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident with dysphagia and hemiplegia following a cerebral infarction. The resident was admitted with a tube feeding requirement, and the facility's policy mandates that feeding tubes be used in accordance with current clinical standards and manufacturer's guidelines. However, the facility did not comply with these guidelines, as evidenced by the use of an expired enteral nutrition product. Specifically, a bottle of Jevity 1.2 was observed in the resident's room, which had been dated 9/6/24 and was still in use on 9/10/24, exceeding the manufacturer's recommended hang time of 24 to 48 hours. Interviews with facility staff revealed that the nursing staff did not change the Jevity bottle daily as required by the manufacturer's guidelines. Nurse #1, who worked the overnight shift, admitted to leaving the Jevity bottle up for use the next day, despite it being dated 9/6/24. The Regional Nurse confirmed that the nursing staff should have changed the bottle daily and followed the manufacturer's guidelines. This oversight in following the proper protocol for enteral feeding administration led to the deficiency identified by the surveyors.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents. For one resident, the facility did not ensure that a BiPAP machine, essential for managing sleep apnea and asthma, was repaired after it was identified as broken. Despite the resident's cognitive awareness and the presence of a physician's order for BiPAP use, the machine remained unusable for weeks. Staff, including a nurse and the Director of Nursing, were aware of the issue but did not document the malfunction or update the resident's care plan. The resident reported not sleeping well without the BiPAP, and there was no record of any repair request or plan to address the broken equipment. For another resident, the facility failed to administer oxygen therapy in accordance with professional standards and physician's orders. The resident, who required oxygen due to heart failure and other conditions, was observed receiving oxygen at a rate higher than prescribed during multiple observations. The physician's order specified a lower oxygen flow rate, but nursing staff did not adjust the settings accordingly. Interviews with staff revealed a lack of awareness regarding the correct oxygen settings, and the resident was not known to adjust the settings independently. This inconsistency in oxygen administration was not aligned with the resident's care plan and physician's orders.
Incomplete Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive plan of care for trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy on trauma-informed care, dated March 2024, requires a multi-pronged approach to identify a resident's history of trauma and cultural preferences, including identifying triggers that may re-traumatize residents. However, the care plan for the resident admitted in August 2024 was incomplete, lacking specific triggers and interventions to mitigate the effects of PTSD episodes. Interviews with the Director of Nursing (DON) and the MDS Nurse confirmed the deficiency. The DON acknowledged that the PTSD care plan was not complete or resident-centered, and it should have included specific triggers and interventions. The MDS Nurse stated that care plans are supposed to be resident-specific with tailored interventions. The failure to include these critical elements in the care plan represents a deficiency in providing trauma-informed care to the resident.
Failure to Indicate Duration of PRN Antipsychotic Medication
Penalty
Summary
The facility failed to indicate the duration of a PRN antipsychotic medication for a resident, which is a requirement according to their policy on the use of psychotropic medications. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration, typically 14 days. If the medication needs to be extended beyond this period, the attending physician must document the rationale and indicate the duration in the resident's medical record. In this case, the facility did not comply with this requirement for a resident who was prescribed Olanzapine as needed for agitation. The resident, who was admitted with diagnoses including borderline personality disorder, suicidal ideations, major depression disorder, and opioid abuse, had a PRN order for Olanzapine without a specified duration. The Psychiatric Nurse Practitioner recommended discontinuing the PRN Zyprexa, stating that antipsychotics should not be PRN unless scheduled. Despite this recommendation being communicated to the Director of Nurses, the facility did not address the issue within the expected timeframe, leading to a deficiency in the management of the resident's medication orders.
Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to ensure that the physician-ordered therapeutic diet was followed for a resident with dysphagia and hemiplegia following a cerebral infarction. The resident was admitted with a tube feeding and was on a mechanically altered diet. Despite having a physician's order for a regular diet with dysphagia advanced texture and thin liquids, the resident was observed receiving a meal that did not comply with these specifications. The meal provided included breaded fish, whole coleslaw, whole French fries, and whole pineapple tidbits, which did not align with the prescribed diet of soft plain baked minced fish, soft minced carrots, mashed potatoes, and pureed fruit. Interviews with dietary staff revealed that the kitchen had recently changed food vendors and had not received updated therapeutic diet breakdowns. As a result, dietary staff were preparing meals based on memory of previous diets. The Food Service Director confirmed the lack of therapeutic diet breakdowns and stated that dietary staff should follow the diet as ordered. The Chief Nursing Officer and Regional Nurse both emphasized the importance of adhering to physician-ordered therapeutic diets, highlighting a breakdown in communication and procedure within the dietary department.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, specifically a lip plate, which was necessary for the resident's meals. The resident, admitted in November 2020, had diagnoses including dementia, dysphagia, and osteoarthritis, and was on a mechanically altered diet. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment and significant weight loss. Despite a physician's order dated April 2023 specifying the need for a lip plate on all meal trays, observations on two separate days in September 2024 revealed that the resident was served breakfast without the required lip plate. Interviews with various staff members, including a Certified Nurse Assistant, a nurse, the Food Service Director, and the Regional Nurse, confirmed that the kitchen was responsible for providing the lip plate. However, the failure to consistently provide this adaptive equipment was evident, as the resident did not receive the lip plate during the observed meals. This oversight highlights a lapse in the facility's adherence to its policy on adaptive feeding equipment, which mandates that the dietary department be notified of residents needing such equipment and that it be provided and maintained appropriately.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's Administrator. The Health Care Facility Reporting System (HCFRS) indicated that a change in the facility administrator occurred on June 21, 2024, with Administrator #2 being the current Administrator. However, during an interview on September 10, 2024, Administrator #1 stated that he started on September 9, 2024. Further review of HCFRS showed no indication that the State Agency was notified when Administrator #1 assumed the role. Additionally, during an interview on September 12, 2024, Administrator #2 confirmed her last day was September 6, 2024. The Chief Nursing Officer acknowledged that the change in Administrator should have been reported to the State Agency but was not.
Failure to Provide Accurate Cost Estimates on ABN Notices
Penalty
Summary
The facility failed to provide an accurate estimated cost of services to residents or their representatives, which is necessary to inform them of their potential financial liabilities for services not covered by Medicare. This deficiency was identified through a review of records and interviews, affecting two residents who had transitioned off their Medicare Part-A benefits but remained at the facility. The Advanced Beneficiary Notices (ABNs) given to these residents did not include a detailed cost breakdown for services, which is required to help residents make informed decisions about continuing services that may not be covered by Medicare. During interviews, both the Business Office Manager and the Administrator acknowledged that the ABN notices lacked the necessary cost breakdown.
Failure to Transmit MDS Discharge Assessment Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment was encoded and transmitted in a timely manner for one resident out of a total of 17 sampled residents. According to the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a discharge MDS assessment must be completed within 14 days after the discharge date. The resident in question was admitted to the facility in April 2024 with diagnoses including pancreatitis and skin cancer. The MDS assessment dated April 18, 2024, indicated the resident's recent admission. However, the resident was discharged home on May 22, 2024, and the medical record did not show that an MDS discharge assessment was encoded or transmitted as required. Interviews with the Director of Nursing and the MDS Nurse confirmed that the discharge assessment was not completed, although it should have been according to RAI guidelines.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, who was admitted with a history of stroke and congestive heart failure, the MDS inaccurately indicated the use of anticoagulant and antiplatelet medications. A review of the Medication Administration Record (MAR) for the relevant period showed no administration of these medications, which was confirmed by both the Director of Nursing and the MDS Nurse during interviews. The MDS Nurse acknowledged the error in coding, as the resident did not receive the medications during the specified lookback period. Another resident, admitted with diagnoses including hip fracture and malnutrition, had their discharge location incorrectly coded in the MDS. The MDS indicated a discharge to an acute care hospital, while progress notes from nursing and social services documented a discharge to another long-term care facility. The MDS Nurse confirmed that the MDS was inaccurately coded, as the resident was indeed discharged to another nursing home. These inaccuracies in MDS coding reflect a failure in ensuring accurate resident assessments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily in a prominent place accessible to residents and visitors. The facility's policy, dated 3/4/24, mandates that the Nurse Staffing Sheet should be posted daily, containing details such as the facility name, current date, resident census, and the total number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides. However, during observations on 9/10/24 and 9/12/24, the surveyor was unable to locate the nurse staffing information in the reception area, indicating non-compliance with the policy. Interviews revealed that the Scheduler, responsible for posting the information, admitted to forgetting to post it on 9/12/24 and confirmed that it was not posted on 9/10/24 due to her absence. Furthermore, the Scheduler stated that the information is not posted on weekends as no one else is assigned this responsibility. The Director of Nursing confirmed that the information should be posted daily, including weekends, highlighting a lapse in the facility's adherence to its staffing information posting policy.
Failure to Follow Established Meal Menus
Penalty
Summary
The facility failed to ensure that the Dietary/Kitchen Department staff consistently prepared and followed the established weekly menu for resident meals. The facility's policy required that menus be developed to meet resident choices and nutritional needs, be posted one week in advance, and be followed as posted. However, during a kitchen tour, it was observed that the breakfast and lunch meals served did not match the planned menu. For breakfast, hashbrowns and gravy were not available, and sausage, which was not on the menu, was served instead. For lunch, a cold tuna sandwich was served instead of the planned tuna melt, and the alternate meal was a grilled cheese sandwich instead of honey Dijon chicken. Interviews with staff revealed that there were issues with Cook #1 not following the planned meal menus, which led to deviations from the posted menu. It was noted that there were missing ingredients for the lunch meal, and Cook #1 had previously used ingredients intended for future meals, causing further menu deviations. A resident reported being served random food not on the planned menu and often having no alternate meal choice other than peanut butter and jelly sandwiches. The facility administrator acknowledged that meal menus should be followed as planned but were not.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages provided to residents were served at safe and appetizing temperatures. The facility's policies required hot foods to be maintained at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, during a test tray observation, it was found that the food items were not served at these temperatures. For instance, a cold tuna sandwich was served at 69.1 degrees Fahrenheit, and mixed vegetables were at 106.9 degrees Fahrenheit, both outside the acceptable temperature range. Additionally, the food was described as bland, with the sandwich being soggy and the tater tots undercooked and cold. The facility's records indicated a lack of consistent measurement and recording of food temperatures. The Service Line Checklist Logs showed numerous instances where no food temperatures were recorded for various meals throughout August and early September. Staff interviews revealed that food temperatures should be measured and documented with every meal, but this was not consistently done. The facility's kitchen staff admitted to not measuring food temperatures due to being too busy, and there was a lack of sufficient food prepared for test trays. Residents expressed dissatisfaction with the quality and temperature of the food. During interviews, residents complained about the food being unappetizing, with one resident stating that breakfast was atrocious and lacking in protein. Another resident mentioned that the lunch sandwich had very little filling and was difficult to identify as tuna or chicken salad. Staff also acknowledged the residents' complaints, with one nurse offering alternative food options like peanut butter and jelly sandwiches. The facility had recently hired a new Food Service Director, but the interim director was filling in until the new director started. The administrator was unaware of the use of paper plates and had not reviewed the Food Committee Meeting Minutes until prompted by the surveyor.
Inconsistent Documentation of Weekly Skin Assessments
Penalty
Summary
The Facility failed to maintain complete and accurate medical records for two residents, as required by their policies. For one resident, who was admitted in April 2024 with diagnoses including epilepsy and hypertension, the Facility's records showed that weekly skin checks were not documented for several weeks. Specifically, there was no documentation for the weeks of April 29, May 6, May 13, and May 20, 2024, and no further documentation after May 27, 2024, despite the care plan indicating that weekly skin checks should be conducted. For another resident, admitted in September 2021 with diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, and anxiety, the Treatment Administration Record indicated that weekly skin checks were scheduled and marked as completed in August 2024. However, the Medical Record lacked completed Weekly Skin Assessment Forms for two of those weeks, specifically August 14 and August 21, 2024. The Director of Nurses confirmed that weekly skin checks should be documented in the electronic medical record, but this was not done consistently.
Delayed Notification of Resident's Death to HCA and Hospice
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) and the Hospice Agency in a timely manner following the death of a resident who was under hospice care. The resident, who had multiple diagnoses including respiratory failure and congestive heart failure, was admitted to hospice services and had an activated Health Care Proxy. The resident passed away shortly after midnight, but the HCA and Hospice Agency were not informed until approximately eight hours later when a family member arrived at the facility expecting to visit the resident. The delay in notification was attributed to the actions of the former Director of Nurses (DON), who was responsible for pronouncing the death but did not do so promptly. A Licensed Practical Nurse (LPN) on duty at the time was unable to pronounce the death and was waiting for the former DON to complete the pronouncement before notifying the HCA and Hospice Agency. The LPN later realized that she could have contacted the Hospice Agency directly, which could have sent a nurse to pronounce the death. The current DON acknowledged the delay and stated that it was expected for nursing staff to notify the relevant parties immediately after a resident's death.
Failure to Maintain Resident Dignity
Penalty
Summary
The Facility failed to maintain Resident #1's dignity when the resident was observed with dirty and soiled sneakers. Resident #1, who has multiple diagnoses including hemiplegia, psychotic disorder, vascular dementia, and dysphagia, was seen in a wheelchair with sneakers that had dried red liquid and food particles on them. This observation was made during a tour of the first-floor unit and later in the activity room, where the condition of the sneakers remained unchanged. Interviews with family members and staff revealed that Resident #1 was a messy eater and often had food stains on clothing, which were not promptly addressed by the nursing staff. Certified Nurse Aide (CNA) #3 acknowledged the condition of the sneakers and stated they should have been cleaned. The Director of Nursing (DON) confirmed that the sneakers should not have been put on the resident in that condition, emphasizing that it was a resident dignity issue.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The Facility failed to ensure a clean and homelike environment for a resident, as evidenced by the condition of the resident's wheelchair. The wheelchair was observed to have multiple areas of dried food caked to the sides and the seatbelt. The resident's wheelchair had not been cleaned for approximately six weeks, despite the facility's policy indicating that wheelchairs should be washed at least once monthly and more often if needed. Staff interviews confirmed that the wheelchair cleaning schedule had not been followed consistently since the former administration left, and the resident's wheelchair was notably dirty, preventing the use of the wheelchair tray for meals. The Housekeeping Director acknowledged that the wheelchair cleaning had not been consistent due to staffing issues, and the Director of Nursing confirmed that the wheelchair should have been cleaned immediately upon observation of its condition. The deficiency was identified during a surveyor's tour and subsequent interviews with facility staff, highlighting a lapse in maintaining a clean and safe environment for the resident, as required by the facility's policy on resident rights.
Failure to Timely Address Medical Emergency
Penalty
Summary
The facility failed to protect a resident from neglect when a significant change in condition was reported. Specifically, Nurse #1 did not assess the medical emergency in a timely manner and failed to call 911 immediately when the resident exhibited symptoms such as chest pain, inability to sit up, significantly elevated blood pressure, a high pulse rate, and loss of the ability to open the left eye. The nurse also failed to provide ongoing monitoring and assessment of the resident's condition. The resident was transferred to the hospital over two hours after the change in condition was noted and subsequently died of septic shock and pneumonia. The resident was admitted to the facility with diagnoses including hypertension, a fall with fracture, and atherosclerotic heart disease. The resident was cognitively intact and required assistance with daily activities. On the day of the incident, a CNA reported to Nurse #1 that the resident was not looking well and was unable to sit up. Despite this, Nurse #1 delayed in calling 911 and did not administer the prescribed Nitroglycerin for chest pain. The nurse also failed to stay with the resident or call for additional help from other staff members. Interviews with staff and review of the resident's medical records revealed discrepancies in the timeline of events and a lack of immediate action by Nurse #1. The Director of Nursing confirmed that Nurse #1 should have called 911 immediately after assessing the resident's condition and then notified the Nurse Practitioner. The delay in calling 911 and the failure to administer appropriate medication contributed to the resident's deteriorating condition and eventual death.
Failure to Respond Timely to Significant Change in Condition
Penalty
Summary
The facility failed to ensure that licensed nursing staff had the appropriate competencies and skill set to identify, assess, and respond to a significant change in condition for one resident. Specifically, the facility did not alert EMS for over two hours when the resident presented with symptoms including chest pain, elevated blood pressure and pulse, weakness, and the inability to open their left eye. Nurse #1, who was informed of the change in condition by a CNA, did not respond timely and only notified the Nurse Practitioner after a significant delay. The resident was eventually sent to the hospital but died there. The resident had a history of hypertension, fall with fracture, and atherosclerotic heart disease. The facility's assessment indicated that staff competencies included recognizing changes in resident acuity and reporting significant changes in a timely manner. However, Nurse #1 was not adequately trained in emergency procedures and believed she needed an order to call 911. The Staff Development Coordinator confirmed that emergency training had not been conducted recently, and the Director of Nursing stated that Nurse #1 should have called 911 immediately after assessing the resident's condition.
Failure to Properly Date and Discard Expired Medications
Penalty
Summary
The facility failed to ensure that open medications were dated as required on two out of four sampled medication carts. On the second floor Unit medication cart, the surveyor observed a Fluticasone Propionate Nasal Spray and an Albuterol inhaler, both of which were opened and not properly dated according to the manufacturer's instructions. Additionally, two boxes of Carbamide Peroxide Ear Drops were found open and undated, making it impossible to determine their expiration dates. On the first floor Unit medication cart, the surveyor found a bottle of Sodium Bicarb that was opened and not properly dated, with the manufacturer's expiration date indicating it had expired in April 2023. Furthermore, a box of Banophen Allergy Capsules and a bottle of Fiber Therapy Psyllium Husk were also found open and undated, with the manufacturer's expiration dates indicating they had expired in January 2023 and July 2023, respectively. During interviews, Nurse #3 confirmed that medications need to be dated when opened and that expired medications should be discarded. The Director of Nursing (DON) also stated that medications should be dated when opened and have an expiration date listed, and that all expired medications should be removed from the cart and not administered to patients. The facility's policy on medication storage, dated October 2019, supports these practices, indicating that beyond-use dating for multi-dose containers is 30 days unless otherwise specified by the manufacturer, and that no expired medication should be administered to residents. All expired medications should be removed from the active supply and destroyed in the facility.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to discrepancies between documented care and observed care. Resident #22, diagnosed with Alzheimer's disease and at risk for pressure ulcers, was observed multiple times with heels directly on the mattress despite a physician's order to float heels every shift. The Treatment Administration Record (TAR) inaccurately indicated that the treatment was completed. Similarly, Resident #45, with diagnoses including Parkinson's disease, was observed with an air mattress set to 100 lbs, contrary to the physician's order for a setting of 150 lbs. The TAR inaccurately documented that the air mattress was checked and set correctly every shift. Resident #13, diagnosed with congestive heart failure, was observed receiving oxygen at 3 liters per minute, contrary to the physician's order for 0-2 liters per minute. The TAR inaccurately indicated that the correct oxygen settings were maintained. Lastly, Resident #15, with severe cognitive impairment, was observed without tubi grips or ted stockings, despite a physician's order to apply them every morning. The TAR inaccurately documented that the stockings were applied. Interviews with nursing staff confirmed that the documented treatments were not performed as required, highlighting a failure in maintaining accurate medical records and following physician orders.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices on two resident units. Specifically, during a dressing change, a nurse did not perform hand hygiene at multiple critical points, including after removing gloves and before donning new ones. This failure to follow proper hand hygiene protocols was observed multiple times during the procedure, despite the nurse acknowledging the expectation to wash hands before and after glove use. Additionally, another nurse was observed using her bare finger to place medication in a cup and using alcohol wipes, which are not approved for disinfecting medical equipment, to clean a glucometer. This nurse also failed to disinfect a blood pressure cuff and pulse oximeter between resident uses, instead placing the contaminated equipment in her pocket and using it on another resident without proper cleaning. Further observations revealed that another nurse also failed to disinfect shared medical equipment between resident uses. This nurse used the same blood pressure cuff and pulse oximeter on multiple residents without cleaning them, contrary to the facility's policy of using disinfectant wipes with purple covers (sani-cloth) for such purposes. The Director of Nursing confirmed that alcohol wipes should not be used for disinfecting shared medical equipment and that nurses should not place equipment in their pockets or touch contaminated equipment with bare hands.
Failure to Update Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to review and revise the care plan for a resident admitted with diagnoses including traumatic subarachnoid hemorrhage, cognitive communication deficit, and dysphagia. The resident was noted to be severely cognitively impaired and required assistance with daily activities. Despite nursing notes indicating the resident's behavior of chewing non-food items such as paper napkins and sheets, the care plan did not include any focus, interventions, or methods for staff to monitor this behavior. This oversight was evident in multiple instances where the resident was found chewing on non-food items, and no care plan adjustments were made to address this behavior. During an observation, a CNA served the resident a meal tray that included paper items, despite previous notes indicating that no paper products should be on the tray. The CNA left the room without supervising the resident, who began eating the meal with the paper items still present. Interviews with staff revealed that while some were aware of the resident's behavior, no consistent measures were in place to prevent the resident from accessing non-food items. This lack of supervision and failure to update the care plan contributed to the deficiency identified by the surveyors.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to ensure professional standards of care were followed for two residents. Resident #15, who has severe cognitive impairment and requires total assistance for personal hygiene, was observed on multiple occasions without the prescribed tubi grips or TED stockings on their legs. The physician's order required these to be applied every morning to prevent edema. The Treatment Administration Record for August 2023 did not indicate any refusal of the stockings, and interviews with staff confirmed that the night nurse was responsible for applying them but failed to do so. The Director of Nursing acknowledged that the physician's orders were not followed as expected. Resident #22, who has severe cognitive impairment and is at risk for pressure ulcers, was observed multiple times lying in bed with their heels directly on the mattress, contrary to a physician's order to float the heels every shift. Despite the care plan indicating the risk for pressure ulcers, the staff did not follow the order. Interviews with nursing staff confirmed the failure to adhere to the physician's instructions. The Director of Nursing confirmed that the expectation to follow physician's orders was not met in this case as well.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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