Brush Hill Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milton, Massachusetts.
- Location
- 1200 Brush Hill Road, Milton, Massachusetts 02186
- CMS Provider Number
- 225274
- Inspections on file
- 23
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brush Hill Care Center during CMS and state inspections, most recent first.
The facility failed to manage its administrative team effectively, leading to deficiencies in resident activities, personal needs account management, and employee record maintenance. Additionally, the absence of a designated Infection Preventionist resulted in inadequate infection control measures, including a lack of antibiotic stewardship and infection surveillance. The leadership was unaware of how to stay updated with CDC, CMS, and MDPH guidance.
The facility did not conduct a comprehensive facility assessment involving all required members, as per CMS guidance, and failed to implement mandatory dementia training for staff. The assessment lacked input from essential participants, and several nurses did not complete the required annual dementia training, as confirmed by the Staff Development Coordinator and Administrator.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents who met the criteria and lacked an Antibiotic Stewardship Program. Observations during the survey revealed that several residents did not have EBP in place, and the facility could not provide evidence of infection surveillance. Interviews indicated that the Staff Development Coordinator was not formally designated as the Infection Control Nurse (ICN) and had not agreed to manage the antibiotic stewardship program.
The facility failed to provide mandatory behavioral health training to its direct care staff, as required by its policy. A review of education records for several nurses revealed a lack of training specific to the needs of residents with mental, psychosocial, or substance use disorders, trauma, PTSD, or dementia. The Staff Development Coordinator confirmed the absence of a staff education program and could not provide evidence of training for any of the approximately 80 relevant employees.
The facility failed to develop and implement individualized care plans for several residents, leading to deficiencies in addressing their needs. A resident with gastroesophageal reflux disease experienced multiple hospitalizations due to unmanaged constipation, while another resident with dementia and anxiety was prescribed antipsychotic medication without a care plan identifying target behaviors or interventions. Additionally, a resident with major depressive disorder was not monitored for antidepressant side effects, and another resident receiving antipsychotic medication lacked a care plan. These oversights were acknowledged by the facility's DON.
The facility failed to provide care according to professional standards, resulting in deficiencies such as inadequate medication reconciliation, improper wound care management, and lack of physician notification for significant changes in residents' conditions. These issues led to multiple hospital admissions and inadequate treatment for several residents.
The facility failed to provide meaningful activities for residents on Unit 3A, as staff were observed not engaging with residents, who were left sitting idly with the television on. Interviews revealed that residents were not offered activities, and staff primarily focused on safety rather than engagement. The Activity Director and Administrator acknowledged the need for more activities.
A resident with dementia and malnutrition experienced unplanned weight loss due to the facility's failure to provide nutritional supplements as ordered. Despite physician orders for supplements when meal intake was below 50%, records showed they were not consistently administered. Interviews with staff revealed a lack of awareness and monitoring of the as-needed supplement orders.
The facility failed to ensure proper communication and implementation of dialysis care for two residents with ESRD. One resident continued to receive a medication despite a recommendation to hold it, due to a lack of communication with the physician. Another resident's Dialysis Communication Records were frequently incomplete, missing essential information needed for coordinating care. These deficiencies indicate a failure to adhere to established policies and agreements for dialysis care.
The facility failed to limit PRN orders for psychotropic medications to 14 days for three residents, as required by policy. A resident had an open-ended PRN order for Ativan without physician review, while two other residents received Valium multiple times over several months without reevaluation or documented rationale for continued use. Staff were unaware of the requirement to limit PRN orders and document clinical rationale for extensions.
The facility failed to serve food at an appetizing temperature, as residents reported receiving cold meals. A test tray confirmed that food items were below appropriate temperature ranges, with pasta at 134°F, broccoli at 132.6°F, garlic bread at 113°F, and cranberry juice at 53°F. The Food Service Director acknowledged the issue, noting challenges in keeping hot foods hot and infrequent test tray evaluations.
The facility failed to maintain ice machines in a clean and sanitary manner, with surveyors observing residue and discoloration in three out of four kitchenettes. Staff interviews revealed confusion over cleaning responsibilities, and the facility lacked a procedure for cleaning the machines, despite using them for residents' water and medication passes.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions like chronic wounds, gastrostomy tubes, and urinary catheters, increasing their infection risk. Surveyors noted the absence of EBP signage and PPE, and staff were observed using inadequate protective measures. Interviews revealed a lack of awareness and implementation of EBP among staff, contributing to the deficiency.
The facility failed to implement an Antibiotic Stewardship Program, lacking a policy, protocols, and monitoring systems for antibiotic use. The Director of Clinical Services incorrectly identified the SDC as responsible for the program, but the SDC clarified her role was limited to education and vaccinations, with no infection control nurse or surveillance in place since her employment began.
A resident with dementia and impaired mobility was repeatedly observed without access to a call light, preventing them from notifying staff for assistance. Despite the facility's policy requiring call lights to be within reach, staff interviews confirmed the oversight, highlighting a failure to accommodate the resident's needs.
A facility failed to update a resident's care plan after discontinuing anticoagulant therapy. The resident, with a history of knee surgery, was initially prescribed Eliquis but experienced bleeding, leading to its discontinuation and replacement with aspirin. Despite multiple care plan meetings, the care plan was not revised to reflect this change, contrary to facility policy. The Unit Supervisor acknowledged the oversight.
A resident at the facility, diagnosed with peripheral vascular disease and hypertension, was found to be storing and using a personal lighter, contrary to the facility's Smoking Policy & Procedure. The policy requires that no lighters or matches be retained by residents and that all lighting materials be kept with staff. Interviews and observations revealed that the resident kept a lighter in their room and on their person, and staff had inconsistent understandings of the policy, leading to a failure in maintaining a hazard-free environment.
A facility failed to assess and develop a care plan for a resident with PTSD, despite the resident being cognitively intact and having a documented history of trauma. Staff interviews revealed a lack of awareness and action regarding the resident's trauma, with the social worker acknowledging the absence of PTSD assessments and care planning.
The facility failed to act on recommendations from the Consultant Pharmacist for two residents. One resident, with dementia and hyperlipidemia, had recommendations for lab tests in March 2024, but the MRR was not documented or reviewed by the physician until much later. Another resident, with dementia and heart disease, had similar recommendations in February 2024, but the MRR was not provided to the provider. Both cases showed a lack of timely action on pharmacist recommendations.
A resident with moderate cognitive impairment had a bottle of prescription Chlorhexidine Gluconate mouthwash left unsecured on their overbed table. The resident had informed the nurse they did not want the mouthwash that day, but it was left unattended, contrary to the facility's policy requiring medications to be stored in locked compartments. Both the nurse and unit supervisor acknowledged the error.
The facility failed to maintain accurate medical records for two residents. One resident's weekly skin assessments were not documented despite being signed off in the TAR, while another resident's allergy to adhesives was not recorded in the medical record, leaving medical staff unaware. Interviews confirmed these documentation oversights.
The facility's abuse policy lacked written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. The policy did not include checking with appropriate licensing boards and registries. The Human Resource Director was unaware of such a requirement, and no additional documentation was provided to the survey team.
Deficiencies in Administrative Management and Infection Control
Penalty
Summary
The facility failed to effectively manage and utilize its administrative team, resulting in several deficiencies. The activity department did not meet the needs of all residents, as the activity calendar was not reviewed or monitored, leading to a lack of meaningful and engaging activities. The business office was located out of state, and the Activity Director was responsible for managing residents' Personal Needs Accounts, which interfered with her ability to focus on her primary role. Additionally, the human resources department was also out of state, resulting in incomplete or outdated employee records. The facility also failed to maintain an effective infection control program. The role of the Infection Preventionist was vacant, and the Staff Development Coordinator (SDC) was covering the role without a formal job description or adequate training. This led to the absence of an antibiotic stewardship program, infection surveillance, and the implementation of enhanced barrier precautions. The facility's leadership, including the Administrator and Director of Nursing, were unaware of how to stay updated with current CDC, CMS, and MDPH guidance, contributing to the deficiencies identified during the survey.
Facility Fails to Conduct Comprehensive Assessment and Implement Dementia Training
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment, which is crucial for evaluating the capability of the facility and its resources to provide both emergency and day-to-day care for its residents. The assessment process did not actively involve all required members, such as representatives from the governing body, direct care staff, and input from residents and their families, as mandated by the Centers for Medicare and Medicaid Services (CMS) guidance. The facility's policy outlined a team responsible for conducting the assessment, but the actual assessment conducted in July 2024 did not include all necessary participants, such as the infection preventionist and representatives from various departments like environmental services and rehabilitative services. Additionally, the facility failed to implement the identified competency-based training, specifically the mandatory dementia training for staff. The review of staff education records revealed that several nurses did not complete the required annual four-hour dementia training. Interviews with the Staff Development Coordinator and the Administrator confirmed the absence of a formal dementia training program at the facility, which should have been conducted during orientation and annually thereafter. This lack of training was evident as the Staff Development Coordinator, who had been in the role for four months, found no evidence of the training being completed in 2023.
Inadequate Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that the designated Infection Control Nurse (ICN) adequately managed the infection prevention and control program. Specifically, the ICN did not implement Enhanced Barrier Precautions (EBP) for residents who met the criteria for such measures. During the survey, it was observed that several residents who required EBP did not have these precautions in place. Interviews with the Staff Development Coordinator and the Director of Nurses confirmed that the EBP program had not been implemented in the facility. Additionally, the facility did not have an Antibiotic Stewardship Program in place to monitor and promote the appropriate use of antibiotics. During the survey, the facility was unable to provide evidence of infection surveillance or an active Antibiotic Stewardship Program. Interviews revealed that the Staff Development Coordinator, who was assumed to be responsible for the infection control program, stated she was not the ICN and had not agreed to oversee the antibiotic stewardship program or infection surveillance. She indicated that since her employment began, there had been no designated ICN or antibiotic line listing/surveillance in the facility.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that mandatory behavioral health training was provided to direct care staff, as required by their own policy and facility assessment. The policy, last revised in July 2022, mandates that staff be trained in recognizing changes in behavior indicating psychological distress, implementing and monitoring care plan interventions, and understanding protocols related to mental disorders and trauma. However, upon review of the staff education records for five nurses, it was found that none had received the required training specific to the needs of residents with mental, psychosocial, or substance use disorders, a history of trauma, PTSD, or dementia. During interviews, the Staff Development Coordinator admitted that there was no evidence of behavioral health training for any of the approximately 80 relevant employees at the facility. She noted that when she started working at the facility four months prior, there was no staff education program in place. The facility was unable to provide any additional documentation to the survey team by the time of the exit conference, confirming the lack of compliance with the training requirements.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for four residents, leading to deficiencies in addressing their physical, psychosocial, and functional needs. Resident #5, who was admitted with gastroesophageal reflux disease, experienced multiple hospitalizations due to constipation. Despite being treated and discharged with specific laxative orders, the facility did not create a comprehensive care plan with measurable objectives and timeframes to manage the resident's constipation effectively. Resident #112, diagnosed with dementia, depression, and anxiety, was prescribed antipsychotic medication. However, the facility did not develop a care plan that identified specific target behaviors, individualized interventions, or measurable goals for the use of the medication. This oversight was acknowledged by the Director of Nursing, who confirmed that a care plan should have been in place. Similarly, Resident #14, with major depressive disorder and psychosis, was not monitored for side effects of antidepressant medications as per the care plan. Additionally, there was no care plan for the resident's antipsychotic medication, lacking targeted behaviors and non-pharmacological interventions. Resident #2, who was cognitively intact and receiving antipsychotic medication, also did not have a care plan addressing the medication's use, which was recognized as a deficiency by the Director of Nursing.
Deficiencies in Medication Reconciliation and Wound Care Management
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for several residents, leading to multiple deficiencies. For one resident, the medication reconciliation process was not conducted thoroughly upon readmission, resulting in the omission of necessary medications and incorrect dosages. This oversight led to the resident experiencing prolonged periods without bowel movements, despite having orders for PRN laxatives, which were not administered as required. The lack of consistent monitoring and documentation of the resident's bowel movements further exacerbated the issue, resulting in multiple hospital admissions for constipation. Another resident with chronic lower extremity wounds did not receive all components of the wound care recommendations from the Wound Consultant. The facility's staff failed to implement the recommended treatments, which included specific dressing applications and skin prep. Despite the Wound Consultant's expectations for these recommendations to be followed, the orders were not transcribed correctly, leading to inadequate wound care management. Additionally, the facility did not obtain necessary physician orders for hospital transfers for a resident, nor did they notify physicians of significant changes in other residents' conditions, such as elevated blood sugar levels and gastric residuals. These lapses in communication and documentation indicate a failure to adhere to established protocols for managing changes in residents' medical conditions, potentially compromising their health and safety.
Lack of Meaningful Activities for Residents on Unit 3A
Penalty
Summary
The facility failed to provide a meaningful and engaging activity program for residents on Unit 3A, as observed by surveyors over several days. The observations revealed that staff members were present in the activity room but did not engage with the residents, who were often left sitting with the television on, but not watching it. The lack of engagement and meaningful activities was consistent across multiple observations, with residents either sitting idly or engaging in minimal activities such as eating cookies and coffee without staff interaction. Interviews with residents and their representatives further highlighted the deficiency. Several residents expressed that they were not offered activities or that the facility did not follow through with scheduled activities. One resident mentioned staying in bed most of the time due to the lack of activities, while another noted that they were not invited to attend activities off the unit. A resident representative also observed that residents in the activity room were not involved in any activities during visits. Staff interviews indicated that CNAs rotated in the activity room primarily to ensure resident safety rather than to engage them in activities. The Activity Director acknowledged the limited scope of activities on Unit 3A, mentioning a monthly game and a daily coffee social as the primary activities. The Administrator admitted that the Activity Department required enhancements and that the facility should be offering more activities than they currently were.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement nutritional interventions as ordered for a resident with a history of dementia, adult failure to thrive, and moderate protein-calorie malnutrition, leading to an unplanned gradual weight loss. The resident, who was severely cognitively impaired, had a documented progressive weight loss from 110.4 pounds to 94.0 pounds over several months. Despite having physician orders for nutritional supplements to be provided when meal intake was less than 50%, the facility did not consistently administer these supplements as needed. The August and September 2024 Medication Administration Records (MAR) showed no evidence that the as-needed supplements were provided on numerous occasions when the resident consumed only 0-25% of meals. Interviews with facility staff, including a nurse, unit manager, dietitian, physician assistant, and the Director of Nurses, revealed a lack of awareness and monitoring regarding the as-needed supplement orders. The nurse was unsure about the as-needed order, and the dietitian did not monitor the documentation and administration of these supplements. The unit manager and DON acknowledged that the supplements should have been provided and documented as ordered. The physician assistant noted the resident's continued weight loss despite the existing orders for nutritional interventions, indicating a failure to follow the treatment plan.
Deficiencies in Dialysis Care Communication
Penalty
Summary
The facility failed to ensure proper communication and implementation of dialysis care for two residents with end-stage renal disease (ESRD). For Resident #19, the facility did not notify the physician or physician extender of a recommendation from the dialysis center to hold the medication Sevelamer due to low phosphorus levels. As a result, the medication was administered for 18 extra doses, despite the recommendation to hold it. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the dialysis recommendations were not communicated or followed up on. For Resident #76, the facility did not complete the Dialysis Communication Records adequately. The records, which are essential for relaying clinical information and coordinating care, were found to be incomplete on multiple occasions. Specific fields that were supposed to be filled out prior to or on the day of dialysis were left blank, and in some instances, entire communication sheets were missing from the resident's medical record. The DON acknowledged that the communication records were incomplete and should have been fully completed each time the resident left for dialysis. These deficiencies highlight a lack of adherence to the facility's policy and the Nursing Home Dialysis Transfer Agreement, which require effective communication and coordination between the nursing facility and the dialysis center. The failure to properly document and communicate critical information regarding dialysis care compromised the standard of care for these residents.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days unless a documented rationale for extended use was provided by the attending physician or prescribing practitioner. This deficiency was identified for three residents out of a sample of 24. Resident #31 had a PRN order for Ativan that was not reviewed or limited to 14 days, and the nurse practitioner was unaware of the open-ended order. Resident #112 had a PRN order for Valium that was administered multiple times over several months without reevaluation or documented rationale for continued use. The unit supervisor acknowledged the oversight of not having a stop date for the order. Similarly, Resident #173 had a PRN order for Valium that was administered several times over two months without reevaluation or documented rationale for its continued use. The physician was unaware of the requirement to limit PRN orders to 14 days and to document a clinical rationale for extending the order. The facility's policies on psychotropic medication use require that PRN orders be necessary for a specific condition and that any extension beyond 14 days be documented with a rationale, which was not adhered to in these cases.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, as evidenced by observations, test tray results, and resident interviews. During the initial resident screening, multiple residents expressed concerns about the food being served cold, including hot foods. The Food Committee Meeting Minutes from previous months also indicated issues with food temperatures and quality, such as cold French fries and inconsistent food temperatures. On a specific date, a lunch test tray was conducted, revealing that the temperatures of the food items were below the appropriate ranges, with pasta at 134°F, broccoli at 132.6°F, garlic bread at 113°F, and cranberry juice at 53°F. The Food Service Director acknowledged the problem, stating that maintaining hot food temperatures has been challenging and that test trays are conducted infrequently, approximately once a month.
Failure to Maintain Ice Machine Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in maintaining the cleanliness of ice machines in three out of four kitchenettes. Observations by the surveyor revealed yellowish and black residue on plastic components inside the ice machines, with water dripping into the ice cubes. The ice machines were used to provide ice for residents' water and medication passes. The facility's policy required ice machines to be cleaned and disinfected according to the manufacturer's instructions, but the cleaning schedules were either blank or not posted, indicating a lack of regular maintenance. Interviews with staff, including a Certified Nursing Assistant, a nurse, the Food Service Director, and the Director of Operations, highlighted a lack of clarity regarding responsibility for cleaning the ice machines. The Food Service Director admitted the machines were not cleaned monthly and expressed uncertainty about the cleaning process. The Director of Operations expected monthly checks and completed cleaning logs but was unsure whether housekeeping or dietary staff were responsible. The Administrator confirmed the absence of a cleaning procedure for the ice machines, despite acknowledging the need for one.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for five residents with conditions that increased their risk of infection. These residents included individuals with chronic wounds, gastrostomy tubes, tracheostomies, and indwelling urinary catheters. Despite the presence of these conditions, the facility did not display EBP signs or provide personal protective equipment (PPE) outside or inside the residents' rooms, as observed by surveyors on multiple occasions. For Resident #68, who had chronic wounds, there was no EBP signage or PPE available, and staff were observed using only gloves during high-contact care activities. Interviews with nursing staff and the Director of Nurses revealed a lack of awareness and implementation of EBP, as they believed standard precautions were sufficient. Similarly, Residents #173, #112, and #31, who had wounds, gastrostomy tubes, and a urinary catheter, respectively, were not placed on EBP, and staff were observed providing care without the appropriate PPE. Resident #19, with an arterial wound, also did not have EBP implemented, as confirmed by the absence of signage and PPE. Interviews with staff, including the Staff Development Coordinator and the Director of Nurses, indicated that the facility had not yet implemented EBP, despite acknowledging that residents with wounds or indwelling medical devices should be on such precautions. This lack of implementation and awareness contributed to the deficiency in infection control practices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The surveyors found that the facility did not have an Antibiotic Stewardship Policy available for review, nor did it provide evidence of antibiotic use protocols or a system to monitor antibiotic use, such as infection surveillance or a line listing. The only documentation provided was a binder labeled Antibiotic Stewardship, which contained outdated information from 2018 and no relevant data from the past year. During interviews, the Director of Clinical Services indicated that the Staff Development Coordinator (SDC) was responsible for the Infection Control Program and antibiotic stewardship, but the SDC stated she was not the Infection Control Nurse and had not agreed to oversee the antibiotic stewardship program. The SDC mentioned that her responsibilities were limited to education and vaccination efforts, and since her employment began in February, there had been no infection control nurse or antibiotic surveillance in place. The facility's failure to establish a monitoring and tracking system for antibiotic use was evident, and no additional information was provided to the survey team by the end of the survey.
Failure to Provide Accessible Call System for Resident
Penalty
Summary
The facility failed to ensure a reasonable accommodation for a resident, specifically by not providing access to the call system for assistance. The resident, who was admitted in March 2020, had diagnoses including dementia, venous insufficiency, and chronic wounds to the lower extremities. The Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and had impaired mobility in both lower extremities. Multiple observations by the surveyor over several days revealed that the call light was consistently out of reach for the resident, who expressed having no way to notify staff for help. Interviews with various staff members, including a rehab staff, CNA, unit manager, and nurse, confirmed that the call light should always be within reach of residents. Despite this, the resident was repeatedly found without access to the call light, and staff acknowledged the oversight. The facility's policy on the call system, revised in September 2022, mandates that each resident should have a means to call staff directly for assistance, which was not adhered to in this case.
Failure to Update Care Plan for Discontinued Anticoagulant Therapy
Penalty
Summary
The facility failed to review and revise the care plan for a resident, specifically regarding the discontinuation of anticoagulant therapy. The resident, who was admitted in August 2017, had a history of traumatic fracture and a right artificial knee joint. Following knee surgery in June 2023, the resident was prescribed Eliquis for deep vein thrombosis prophylaxis. However, after experiencing bleeding from the surgical site, the Eliquis was discontinued on June 27, 2023, and replaced with aspirin. Despite this change, the care plan was not updated to reflect the discontinuation of Eliquis. The care plan meetings held on several occasions, including November 2023, March 2024, April 2024, and July 2024, did not address the necessary revision to the care plan. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in this case. The Unit Supervisor confirmed that the care plan should have been updated to reflect the discontinuation of anticoagulant therapy when Eliquis was stopped.
Failure to Securely Store Smoking Materials
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not ensuring that smoking materials were securely stored for a resident who was identified as an independent smoker. The facility's Smoking Policy & Procedure mandates that no lighters or matches should be retained by residents and that all lighting materials should be kept with staff and returned to a designated area after use. However, it was observed that a resident, who was admitted with diagnoses including peripheral vascular disease and hypertension, stored a lighter in their locked bedside drawer and carried it on their person, contrary to the facility's policy. Interviews with the resident and staff revealed inconsistencies in the understanding and enforcement of the smoking policy. The resident admitted to keeping a lighter in their room and on their person, while the Unit Supervisor incorrectly believed that independent smokers could keep their smoking materials. The Director of Nursing expected lighting materials to be stored at the front desk, but the front desk secretary confirmed that the resident sometimes used their own lighter instead of the one stored securely at the front desk. Observations confirmed that the resident bypassed the front desk and used a personal lighter to smoke, indicating a lapse in policy enforcement and supervision.
Failure to Assess and Plan for Resident's Trauma History
Penalty
Summary
The facility failed to assess and develop a care plan for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD). The resident, who was admitted in April 2022, was cognitively intact and had a diagnosis of PTSD, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the resident's PTSD being documented in social service progress notes and identified as a focus area in therapy sessions, the facility did not conduct a trauma assessment or create a care plan with individualized interventions to prevent potential re-traumatization. Interviews with facility staff revealed a lack of awareness and action regarding the resident's trauma history. A Certified Nursing Assistant and a nurse both stated they were unaware of the resident's past trauma. Additionally, the social worker admitted that PTSD or trauma assessments were not conducted, citing a lack of assessment tools and an oversight in developing a care plan for the resident. This oversight resulted in the absence of a structured approach to address the resident's trauma-related needs and preferences.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act promptly on recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two residents. Resident #10, admitted with dementia and hyperlipidemia, had recommendations made in March 2024 to obtain a Valproic Acid Level, Liver Function Tests (LFTs), and a Vitamin D level to assess medication efficacy and potential side effects. However, there was no documented evidence of the March 2024 MRR in the resident's medical record, and the physician/prescriber response section was left blank. The Director of Nursing (DON) admitted that the MRR was not provided to the physician until the week before the interview, indicating a delay in implementation. Similarly, Resident #69, admitted with dementia and heart disease, had recommendations made in February 2024 to obtain LFTs, a Vitamin B12 level, and a folate level. Like Resident #10, there was no documented evidence of the February 2024 MRR in the medical record, and the physician/prescriber response section was also blank. The DON confirmed that the MRR for Resident #69 had not been provided to the provider, demonstrating a failure in the facility's process to ensure timely review and action on the pharmacist's recommendations.
Unsecured Medication Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by an incident involving a resident with moderate cognitive impairment. The resident, who had a gastrostomy and was admitted in July 2024, was prescribed Chlorhexidine Gluconate Mouth/Throat Solution to be administered once daily. On a survey conducted in September 2024, a surveyor observed a 16-ounce bottle of the prescription mouthwash left unsecured on the resident's overbed table. The resident mentioned that they had informed the nurse earlier that they did not want the mouthwash that day, and the nurse left it on the table. The facility's policy on medication labeling and storage requires that all medications be stored in locked compartments, accessible only to authorized personnel. However, the prescription mouthwash was left unattended, contrary to the policy. During interviews, both the nurse involved and the unit supervisor acknowledged that the mouthwash should not have been left at the resident's bedside, indicating a lapse in following the facility's medication storage protocols.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, the facility did not document weekly comprehensive skin assessments as per physician orders. Although the Treatment Administration Records (TAR) indicated that weekly skin checks were signed off as completed, the actual skin assessment forms were missing for several specified dates. Interviews with the Unit Supervisor and the Director of Nursing confirmed the absence of these assessments, despite the TAR indicating completion. For another resident, the facility did not document a diagnosis of allergic dermatitis from adhesives in the medical record as an allergy. The resident, who had a tracheostomy, was diagnosed with this condition by the facility's consultant wound physician. However, this diagnosis was not added to the resident's allergy list, leaving the attending physician and Physician's Assistant unaware of the allergy. Interviews with the Unit Supervisor and the Physician's Assistant confirmed the oversight in documentation.
Deficiency in Employee Screening Procedures for Abuse History
Penalty
Summary
The facility failed to ensure their abuse policy included written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. During the entrance conference, the surveyor requested to review the facility's abuse prohibition policies and procedures. The Executive Director provided a binder containing the abuse policies, which included a policy titled 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating,' last revised in September 2022. However, this policy did not include procedures for checking with appropriate licensing boards and registries as required. In an interview, the Human Resource Director stated she was unaware of a policy requiring the screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, including checking appropriate registries. No additional documentation related to the facility's abuse policies was provided to the survey team before the exit conference.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
