Brookside Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, Massachusetts.
- Location
- 11 Pontiac Avenue, Webster, Massachusetts 01570
- CMS Provider Number
- 225483
- Inspections on file
- 22
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Brookside Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not complete scheduled deep-cleaning in 12 out of 15 observed rooms, resulting in thick dust accumulation on high surfaces such as overbed light fixtures and televisions. A resident's representative raised concerns about room cleanliness, and staff confirmed that terminal cleaning had not been performed as scheduled. Facility leadership acknowledged there was no monitoring process in place for environmental cleanliness, and the Administrator was unaware of the missed cleanings.
Two residents were not protected from unnecessary psychotropic medication use. One received PRN antipsychotic medication without a required 14-day limit or physician documentation for continued use, while another was maintained on the same antidepressant dosages for over a year without any attempt at gradual dose reduction (GDR) or documentation that a GDR was contraindicated. The DON confirmed these deficiencies and the lack of supporting documentation.
Staff did not follow physician orders for a resident's indwelling urinary catheter, resulting in the use of an incorrect catheter size and failure to perform a scheduled catheter change as documented. The DON confirmed the catheter in use did not match the current orders and the required change had not been completed.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident with multiple respiratory conditions was observed receiving oxygen therapy at 4 LPM via nasal cannula without a physician order in place. Nursing staff and the DON confirmed that oxygen was being administered without the required order, contrary to facility policy and professional standards.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
Surveyors found that both kitchenettes had refrigerators containing expired, unlabeled, and undated food items, as well as spilled food and debris. There was confusion among the Dietary, Housekeeping, and Nursing departments regarding responsibility for cleaning and monitoring these refrigerators, resulting in a lack of scheduled maintenance and oversight.
Surveyors identified that two residents did not have accurate clinical records: one resident's PRN Tramadol administration and its effectiveness were not documented on the MAR, despite the medication being given, and another resident's Foley catheter care was inaccurately recorded, with staff signing off on catheter changes that were not performed and discrepancies in catheter size. These actions were not in accordance with facility policy and professional standards.
A nurse failed to disinfect a multi-use glucometer with a bleach-based product after checking a resident's blood sugar, instead using Lysol wipes not validated for this purpose. The glucometer was then returned to the medication cart for use on other residents, contrary to both facility policy and manufacturer guidelines. The nurse was unaware of the correct procedure, and facility policies had not been updated to reflect the requirements for the newer glucometer model.
The facility did not have policies and procedures in place to ensure residents were assessed for, offered, or administered flu and pneumonia vaccinations, nor was there documentation of vaccine administration or refusal.
The facility failed to accurately complete MDS assessments for three residents, including not coding diuretic use for a resident with heart failure, misclassifying antiplatelet medications as anticoagulants for another, omitting tobacco use for a resident who smoked, and not documenting a therapeutic diet for a resident on dialysis, despite clear evidence in medical records and staff interviews.
The facility failed to conduct interdisciplinary care plan meetings and involve residents or their representatives in the care planning process for four residents. Documentation was missing for care plan meetings following MDS assessments, and residents reported not being aware of or invited to such meetings. The Administrator confirmed the absence of evidence for these meetings.
The facility failed to honor a resident's meal portion request made by the Resident Representative. Despite multiple requests for double meal portions due to the resident's constant hunger, the facility did not evaluate or implement the request. The Food Service Director and Dietitian were unaware of the request, resulting in the resident continuing to receive single meal portions.
The facility failed to develop and implement a care plan for a resident who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents and staff awareness of the behavior, no care plan was created to address these issues, leaving staff without documented interventions to manage the resident's behavior.
The facility failed to provide adequate nutrition care and monitoring for a resident receiving artificial nutrition via a Jejunostomy tube. The staff did not consistently implement, monitor, and evaluate weekly weights, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to adjust tube feed recommendations and offer alternative options when the resident could not tolerate increased tube feeds, leading to significant weight loss and unmet nutritional goals.
The facility failed to provide appropriate respiratory care for two residents by not monitoring and maintaining respiratory equipment, lacking physician orders for oxygen use, and not changing oxygen and nebulizer tubing as required. Observations revealed unsanitary conditions and improper storage of respiratory equipment.
A facility failed to monitor a resident's AV fistula for signs of patency and infection, leading to significant bruising and swelling that required emergency medical intervention and surgery. The resident, who had ESRD and received hemodialysis three times a week, experienced issues due to the lack of proper monitoring and documentation as per facility policy.
A resident with Dementia ingested [NAME] Lotion and house barrier cream due to improper medication storage, resulting in hospitalization and monitoring for gastrointestinal upset. The facility failed to adhere to its medication storage policy, and no staff education was completed following the incidents.
The facility failed to update a resident's Physician's orders to match the MOLST, resulting in a discrepancy between the DNR status indicated in the MOLST and the Full Code status in the EMR. The resident had Dementia with Behavioral Disturbance, and the error was identified during an interview with a nurse.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a tracheostomy and gastrostomy tube. Staff did not wear appropriate PPE, and there was no EBP signage outside the resident's room, despite being aware of the requirements.
The facility failed to accurately code the MDS for two residents. One resident's MDS did not reflect a Stage Four pressure ulcer present on re-admission, and another resident's MDS did not indicate the use of IV hydration despite receiving it. The MDS Nurse confirmed the coding errors.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident and in 12 out of 15 rooms observed across two units. Specifically, the facility did not ensure that the 'room of the day' deep-cleaning was completed according to the established cleaning schedule. Observations revealed thick, dark gray dust on high surfaces such as overbed light fixtures and televisions in multiple rooms. A resident's representative expressed concerns about the lack of cleaning, and staff confirmed that the scheduled terminal cleaning had not been performed in the affected rooms. The Director of Housekeeping was unable to provide evidence of when these rooms were last terminally cleaned. Interviews with facility leadership, including the Director of Housekeeping, DON, and Infection Preventionist, revealed there was no process in place to monitor the cleanliness of the environment. The Administrator was unaware that the rooms had not been cleaned as scheduled and had not been informed when rooms were skipped. The DON recalled a previous family concern about high dusting areas but could not provide details. The failure to follow the cleaning schedule and lack of monitoring led to the observed deficiency in maintaining a safe, clean, and comfortable environment for residents.
Failure to Limit PRN Antipsychotic Use and Attempt Gradual Dose Reduction for Psychotropics
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with vascular dementia and mood disturbances, a PRN order for Haloperidol (an antipsychotic) was issued without a required 14-day limit or documented physician evaluation for continued use. The medication was administered on multiple occasions over several months, and the medical record did not include documentation supporting the extended use or a rationale from a provider. The Director of Nursing confirmed that the order lacked the necessary 14-day duration and supporting documentation for ongoing administration. For another resident with a diagnosis of depression, the facility did not attempt a Gradual Dose Reduction (GDR) for prescribed antidepressant medications, nor did it provide evidence that a GDR was clinically contraindicated. The resident had been receiving the same dosage of two antidepressants for over a year, and the medical record did not reflect any GDR attempts or physician documentation of contraindications. The Director of Nursing acknowledged that no GDR had been attempted and was unable to provide evidence to support that a GDR was considered or contraindicated.
Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter by not following the physician's order regarding the correct catheter size. The resident, who was admitted with urinary retention and obstructive and reflux uropathy, was severely cognitively impaired and dependent on staff for activities of daily living. The physician's order specified a Foley catheter of 16 French with a 10 ml balloon, to be changed as needed for signs and symptoms of infection and routinely once a month. During observation, it was found that the resident had a 14 French Foley catheter in place, and the balloon size was faded and unreadable. Review of the Treatment Administration Record indicated that the catheter change was documented as completed with the correct size, but in reality, the catheter had not been changed as ordered. The Director of Nursing confirmed that the catheter in use did not match the current physician's orders and that the required catheter change had not occurred.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident. Specifically, a resident with diagnoses including Chronic Kidney Disease, Obstructive Sleep Apnea, Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease was observed receiving oxygen therapy at 4 liters per minute via nasal cannula. The resident reported always using oxygen at this rate, and the oxygen concentrator was observed in use during the survey. Upon review of the resident's medical record, there were no physician orders in place for the administration of oxygen therapy. Nursing staff and the Director of Nursing confirmed that oxygen was being administered without a physician's order, despite facility policy requiring all medications and treatments, including oxygen, to have a physician's order. The lack of a physician order for ongoing oxygen therapy constituted a failure to follow professional standards and facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Sanitation and Food Storage Practices in Kitchenettes
Penalty
Summary
Surveyors observed that the facility failed to ensure proper sanitation and food storage practices in both kitchenettes on the [NAME] Unit and [NAME] Unit. Specifically, refrigerators in these areas contained expired food items, such as sour cream, milk, instant Jello, and a supermarket packaged Cobb salad. Additionally, there were multiple unlabeled and undated resident food items, including milk, yogurts, juices, boiled eggs, cut fruits and vegetables, and an open stick of butter. The refrigerators also had spilled food and debris on the shelves, indicating a lack of regular cleaning and maintenance. Interviews revealed confusion and lack of clarity regarding departmental responsibilities for maintaining and cleaning the kitchenette refrigerators. The Food Service Director stated that the Dietary Department was not responsible for these refrigerators and did not maintain a cleaning schedule, believing housekeeping was responsible. The Housekeeping Director, newly employed, was unaware that his department was responsible for refrigerator cleaning and food item checks, and thus had no cleaning schedule in place. The Administrator confirmed that the Dietary Department should have been maintaining the refrigerators and checking for expired or unlabeled items, but this was not occurring. The Administrator also noted that staff and resident food items were improperly stored together and not properly labeled or dated.
Failure to Accurately Document PRN Medication Administration and Foley Catheter Care
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for two residents. For one resident with chronic pain syndrome, the facility did not document the administration of a PRN dose of Tramadol, an opioid analgesic, on the Medication Administration Record (MAR) for a specific date and time, despite evidence from the narcotic book and nurse interview that the medication was given. Additionally, the effectiveness of the PRN Tramadol was not recorded as required by facility policy. The nurse involved acknowledged the omission and confirmed that both the administration and effectiveness should have been documented. For another resident with urinary retention and an indwelling Foley catheter, the facility failed to accurately document the size and care of the catheter. Although physician orders specified a 16 French catheter with a 10 ml balloon, observation revealed the resident had a 14 French catheter in place, and the balloon size was unreadable. The Treatment Administration Record (TAR) indicated that the catheter had been changed to the correct size on multiple occasions, but interviews with nursing staff and the Director of Nursing revealed that the documented catheter changes had not actually been performed, resulting in inaccurate records. These deficiencies were identified through observations, interviews, and record reviews, and were in direct violation of the facility's own policies regarding medication administration and catheter care documentation. The failures involved both the omission of required documentation and the inaccurate recording of care that was not provided.
Failure to Disinfect Glucometer with Required Bleach-Based Product
Penalty
Summary
Facility staff failed to properly implement infection control procedures when disinfecting a multi-use glucometer after use on a resident. Specifically, a nurse used Lysol wipes, which do not contain bleach, to clean the glucometer after performing a fingerstick blood sugar check on a resident with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and type 2 diabetes. The nurse then returned the glucometer to the medication cart for use on other residents. The nurse stated she was unaware that a bleach-based product was required for disinfecting the device and routinely used Lysol wipes as provided by the facility. Facility policy and the manufacturer's operator manual for the Evencare G2 Meter both specify that a bleach-based disinfectant should be used to clean the glucometer, with a required dry time, to prevent the transmission of bloodborne pathogens. The Director of Nursing and Infection Preventionist confirmed that the facility had not updated its policy to reflect the manufacturer's guidelines after switching to the newer glucometer model, resulting in staff not following the correct disinfection protocol.
Failure to Establish Policies for Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified through review of facility practices and documentation, which revealed the absence of established protocols to ensure residents received these vaccinations as recommended. There was no evidence that the facility had a systematic process in place to assess, offer, or document the administration or refusal of flu and pneumonia vaccines for residents.
Inaccurate MDS Assessments for Medications, Smoking, and Diet
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in care planning and delivery. For one resident with vascular dementia and congestive heart failure, the facility did not accurately code the use of diuretic medication on the MDS, despite physician orders and medication administration records confirming the resident received a diuretic during the assessment period. The MDS nurse acknowledged that the medication should have been coded but was not. Another resident with chronic heart failure, morbid obesity, diabetes, and hypertension was incorrectly coded on the MDS as receiving anticoagulant medication, when in fact only antiplatelet medications (aspirin and clopidogrel) were ordered and administered. The MDS nurse admitted to misclassifying the medications, having assumed that clopidogrel was an anticoagulant, and this error was also reflected in the resident's care plan. Additionally, the facility failed to accurately code tobacco use and therapeutic diet status for two residents. One resident, identified as a smoker and care planned for smoking, was incorrectly coded as not using tobacco on the MDS, despite direct observation and interview confirming ongoing smoking. Another resident, with end stage renal failure and on dialysis, was not coded as receiving a therapeutic diet on two consecutive MDS assessments, even though physician orders indicated a prescribed therapeutic diet during the relevant periods. The MDS nurse confirmed these omissions.
Failure to Conduct Interdisciplinary Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct interdisciplinary care plan meetings after Minimum Data Set (MDS) assessments were completed and did not involve the residents or their representatives in the care planning process for four residents. Specifically, the facility did not provide evidence that Resident #2 and their invoked Health Care Proxy (HCP) participated in care planning meetings following MDS assessments completed on two occasions in 2024. The Social Worker (SW) was unable to provide documentation of care plan meetings or attendance records for these assessments, and the Administrator confirmed the absence of such evidence. For Resident #67, the facility did not provide evidence of care plan meetings or participation by the resident or their representative following an MDS assessment completed in January 2024. The resident reported not recalling any invitation or participation in care plan meetings, and the SW and Administrator were unable to provide documentation to support that such meetings occurred. Resident #3's clinical records did not show evidence of care plan meetings or participation by the resident or their representative following MDS assessments completed in December 2023 and March 2024. The resident was unaware of the existence of care plans, and the Administrator could not provide evidence of care plan meetings since December 2023. Similarly, Resident #60's records lacked evidence of care plan meetings following MDS assessments in May and August 2023, and the resident expressed a desire to discuss discharge planning but had not participated in any care plan meetings. The Administrator provided documentation of two care plan meetings in late 2023 and early 2024, but these did not include the resident's participation or an explanation for their absence.
Failure to Honor Resident's Meal Portion Request
Penalty
Summary
The facility failed to ensure that a resident's choices were honored when requested by his/her Resident Representative. Specifically, the facility did not evaluate whether the Resident Representative's request for double meal portions for a resident with Dementia with Behavioral Disturbance was appropriate, nor did they implement the request. The Resident Representative had repeatedly requested double meal portions, citing that the resident was always hungry during family visits. However, there was no follow-up from the facility staff on this request, and the resident continued to receive single meal portions as indicated by the current diet order and communication slip from the kitchen. Interviews with the Food Service Director and the Dietitian revealed that neither was aware of the request for double meal portions. The Food Service Director stated that she would have informed the Dietitian if she had known about the request, and the Dietitian would have assessed the appropriateness of increased portions. The Dietitian confirmed that she would evaluate such requests and provide education to the Resident Representative if increased portions were not suitable. However, no such evaluation or communication occurred in this case, leading to the deficiency.
Failure to Develop and Implement Care Plan for Resident's Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for Resident #14, who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents, including eating the foil covering off an applesauce cup and ingesting various topical medications such as anti-itch lotions and barrier creams, no care plan was created to address these behaviors. Interviews with staff and the resident's representative confirmed the resident's tendency to eat nonfood items, and the need for staff to ensure such items were not within the resident's reach. The Director of Nurses acknowledged that a care plan should have been developed to address Resident #14's behavior of eating nonfood items, but this was not done. The facility's policy on Behavioral Assessment, Intervention, and Monitoring requires the interdisciplinary team to evaluate behavioral symptoms and develop a care plan accordingly, which was not followed in this case. This oversight left staff without documented interventions to manage the resident's behavior, leading to repeated incidents of the resident ingesting nonfood items.
Failure to Provide Adequate Nutrition Care and Monitoring
Penalty
Summary
The facility failed to provide nutrition care and services that meet professional standards of practice for a resident receiving artificial nutrition via a Jejunostomy tube. Specifically, the facility staff did not appropriately implement, monitor, and evaluate weekly weights as ordered for the resident, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to assess tube feed recommendations made by the Registered Dietitian (RD) and did not offer alternative options when the resident was unable to tolerate increased tube feeds and calorie goals. The resident, who was admitted with severe protein-calorie malnutrition, malignant neoplasm of the esophagus, and dysphagia, experienced significant weight loss. Despite the resident's refusal to be weighed on multiple occasions, the facility did not document reasons for the refusals or take appropriate actions to address the issue. The resident's weight was not consistently monitored, and there were gaps in the weekly weight records. The RD and nursing staff did not consistently reassess the resident's nutritional status or adjust the tube feeding regimen to meet the resident's needs. Interviews with the RD, nurses, and CNAs revealed that the resident's nutritional needs were not being met, and there was a lack of coordination and communication among the staff. The resident expressed concerns about their weight and willingness to trial an increase in tube feedings, but the facility did not take timely actions to address these concerns. The failure to monitor and adjust the resident's nutritional care contributed to the resident's continued weight loss and unmet nutritional goals.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents. For Resident #272, the facility staff did not ensure that the aerosol compressor was monitored and maintained for optimal humidification of the resident's tracheostomy tube. Additionally, there was no physician's order for oxygen use and increased liter flow, and the oxygen tubing equipment was not changed as required to prevent contamination and the spread of infections. Observations revealed that the aerosol compressor had run out of water, and the oxygen concentrator was set at 5 liters per minute without proper documentation or orders. The resident's respiratory equipment was also found lying on the floor, which was against the facility's protocol for maintaining sanitary conditions. For Resident #3, the facility staff failed to change the oxygen tubing and nebulizer tubing and mask as ordered. The resident's oxygen tubing and nebulizer tubing were observed to be dated and not changed weekly as required. Additionally, the nebulizer tubing and mask were placed directly on the resident's bedside table instead of being stored in a plastic bag with the resident's name and date. Interviews with the nursing staff confirmed that they were aware of the need to change the tubing and mask but had not done so. The Director of Nurses (DON) acknowledged that the facility did not have the necessary physician orders in place for Resident #272's oxygen use and that the respiratory equipment should have been stored properly. The DON also confirmed that the nebulizer masks and tubing for Resident #3 should be changed weekly and kept in a bag at the bedside. The facility's failure to adhere to these standards resulted in deficiencies in providing safe and appropriate respiratory care for the residents.
Failure to Monitor Hemodialysis Fistula
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice related to hemodialysis for a resident with End Stage Renal Disease (ESRD). Specifically, the facility did not monitor the resident's AV fistula for signs and symptoms of patency and infection. The facility's policy required staff to be trained in the care and special needs of residents with ESRD, including the care of grafts and fistulas, and to document the condition of the fistula site every shift. However, the resident's physician orders did not include necessary nursing interventions for monitoring the fistula site, and the facility's progress notes did not reflect consistent monitoring for signs of infection or patency. The resident, who was cognitively intact, had a new fistula on the right lower extremity and received hemodialysis treatments three days a week. On one occasion, the resident returned from dialysis with significant bruising and swelling in the arm with the fistula, which prevented the dialysis treatment. The resident requested to go to the Emergency Department (ED) for evaluation, and the Nurse Practitioner agreed with this plan. The resident was subsequently hospitalized for several days and required surgery on the right arm. Interviews with the resident and nursing staff revealed that the resident had experienced issues with bruising and swelling at the fistula site. The Director of Nurses (DON) acknowledged that the physician's orders should have included monitoring the fistula for signs and symptoms of infection and patency from the time the fistula was placed, but these orders had not been initiated. This oversight led to the resident's condition worsening and requiring emergency medical intervention.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored safely and remained inaccessible to a resident diagnosed with Dementia with Behavioral Disturbance. The resident ingested [NAME] Lotion, which was left unattended on the nurse's station desk, resulting in hospitalization. Additionally, the resident ingested a mixture of calamine, hydrocortisone, and zinc paste (house barrier cream) that was within reach during care, requiring monitoring for possible gastrointestinal upset. The facility's policy on medication storage was not adhered to, and no staff education was completed following these incidents. The Director of Nurses (DON) confirmed that nursing staff should not leave any medication unattended or within reach of residents. However, the DON was unable to provide documentation that staff education regarding proper medication storage was completed after the incidents. The Root Cause Analysis (RCA) indicated that the lotion and barrier cream were not stored securely, leading to the resident's ingestion of these substances. No additional interventions or education were documented to prevent recurrence.
Failure to Update Physician's Orders to Match MOLST
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident out of 18 sampled. Specifically, the staff did not update the resident's Physician's orders to match the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST). The resident, who was admitted with a diagnosis of Dementia with Behavioral Disturbance, had a MOLST indicating a Do Not Resuscitate (DNR) order. However, the Physician's orders in the electronic medical record (EMR) indicated the resident was a Full Code, which means all life-sustaining treatments, including CPR, should be performed. During an interview, a nurse confirmed that she would refer to the EMR to determine the resident's code status in case of cardiac distress. Upon review, the nurse found a discrepancy between the Physician's orders and the MOLST. The Physician's orders incorrectly indicated the resident was a Full Code, while the MOLST correctly indicated a DNR status. The nurse acknowledged that the Physician's orders should have been updated to match the MOLST when it was completed, but this update had not been made.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for a resident with indwelling medical devices, specifically a tracheostomy and a gastrostomy tube. The staff did not identify the need for Enhanced Barrier Precautions (EBP) for this resident, which is required to reduce the transmission of multidrug-resistant organisms (MDROs). During an observation, a rehabilitation staff member assisted the resident without wearing the appropriate personal protective equipment (PPE), such as a gown, and there was no signage indicating EBP outside the resident's room. Interviews with the rehabilitation staff, the Assistant Director of Nursing (ADON), and the Director of Nurses (DON) revealed that the facility staff were aware of the EBP requirements but failed to implement them correctly. The ADON and DON confirmed that residents with wounds or indwelling medical devices should be on EBP and that proper signage should be in place to communicate the necessary precautions to staff. However, the required EBP signage was missing from the resident's room, leading to non-compliance with infection control standards.
Inaccurate MDS Coding for Pressure Ulcer and IV Hydration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two residents. For Resident #22, the MDS was not accurately coded to reflect the presence of a Stage Four pressure ulcer on re-admission to the facility. The resident, who had a diagnosis of Diabetes Mellitus with Autonomic Neuropathy, returned to the facility with a pressure ulcer on the coccyx. Despite this, the MDS Assessments dated 11/7/23 and 2/6/24 incorrectly indicated that the pressure ulcer was not present at the time of re-admission. The MDS Nurse confirmed that the assessments were coded incorrectly and should have reflected the pressure ulcer as present on re-admission and not facility-acquired. For Resident #29, the MDS was not accurately coded to reflect the use of IV hydration. The resident, who had a diagnosis of Dementia with Psychotic Disturbance, had a physician's order for IV hydration initiated on 2/27/24. The Nursing Progress Notes confirmed that the resident received 500 milliliters of normal saline through a peripheral line. However, the comprehensive MDS assessment did not indicate that the resident had received IV hydration during the assessment period. The MDS Nurse acknowledged that the assessment was coded incorrectly and needed to be modified.
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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