Cambridge Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cambridge, Massachusetts.
- Location
- 8 Dana Street, Cambridge, Massachusetts 02138
- CMS Provider Number
- 225520
- Inspections on file
- 16
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cambridge Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently date and label food and supplemental drinks stored in two unit kitchenettes, with several undated or improperly labeled items observed, including opened containers of food and nutritional supplements. Interviews with the FSD and a nurse revealed confusion and inconsistency in following the facility's food storage policy, resulting in perishable items remaining past the required discard timeframe.
A resident with diabetes and severe cognitive impairment did not have insulin lispro administration accurately documented, despite physician orders requiring its use based on blood sugar readings. Multiple blood sugar checks indicated the need for insulin, but the MAR lacked documentation of administration or refusal. Nursing staff later stated the insulin was given but not recorded, and the DON confirmed a transcription error contributed to the documentation failure.
A resident with right-sided hemiplegia, cognitively intact and dependent on staff for bathing, was not provided showers as requested since admission. Despite repeated requests from the resident and family, and documentation indicating the need for staff assistance and a mechanical lift, the facility failed to provide a suitable shower chair in a timely manner. Staff and leadership interviews confirmed awareness of the issue and acknowledged significant delays in obtaining and modifying the necessary equipment, resulting in the resident only receiving bed baths.
A resident with a history of stroke, traumatic brain injury, and dementia developed worsening upper extremity contractures. Despite a nurse practitioner's recommendation for an occupational therapy (OT) referral, no order was placed and the OT was not notified, resulting in a 49-day delay before the resident was evaluated. Facility staff interviews and record review confirmed that the required referral process was not followed, and no documentation of a referral or contraindications was found.
Surveyors found that staff did not date opened medications with shortened expiry periods, including inhalers and an insulin pen, as required by facility policy. The DON and a unit manager confirmed these medications should have been dated when opened, but were not.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple occasions. Nurses admitted to leaving carts unlocked, and management confirmed that carts should be locked when not in use.
A nurse failed to follow enhanced barrier precautions by not wearing a precaution gown while caring for a resident with a pressure ulcer wound. The facility's policy requires gowns and gloves for high-contact activities, but the nurse only wore gloves. Interviews with staff confirmed the need for a gown, highlighting a lapse in infection control practices.
A resident with dementia and psychosis was found with a bruise of unknown origin, which was not immediately reported to the DON or Administrator as required by the facility's policy. The incident was reported to the state agency 30 hours after staff first became aware of it, indicating a failure to follow the abuse prohibition policy.
A facility failed to update a resident's care plan to reflect their independence in oral hygiene, toileting hygiene, and toilet transfer, as indicated by a comprehensive assessment. Despite being assessed as independent, the care plan continued to list the resident as requiring assistance. The DON confirmed that the interdisciplinary team did not update the care plan as required.
A resident with severe cognitive impairment and at risk for pressure ulcers was observed multiple times without offloading booties on their heels, contrary to physician's orders. Staff interviews confirmed the resident did not refuse the booties, and documentation inaccurately indicated compliance with the order.
A facility failed to ensure the correct size suprapubic catheter was used for a resident, as ordered by the physician. The resident, with conditions including Parkinson's and urine retention, was observed with a catheter that did not match the physician's specifications. Staff interviews revealed a previous catheter change due to leakage, but the correct size was not used, and the resident confirmed the catheter was not changed as ordered.
A resident with a G-tube did not receive the prescribed amount of Jevity 1.5 calorie due to a defect in the feeding machine and lack of routine checks by the nurse. The resident's feeding was supposed to be administered at 60 mL per hour, but observations showed no infusion throughout the day. The DON was aware of the physician's concerns about the feeding being stopped.
A resident with COPD and moderate cognitive impairment was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. The facility's policy requires adherence to physician orders for oxygen therapy, but staff failed to implement the correct flow rate, as confirmed by the DON.
A resident with COPD, stroke, dysphagia, and malnutrition experienced significant weight loss and a decline in mobility, but the facility failed to complete a Significant Change of Status MDS within the required timeframe. The resident's weight dropped from 129 to 109 pounds, and their transfer ability declined from requiring supervision to total dependence. The DON acknowledged the oversight, and the MDS Nurse was unavailable for comment.
Failure to Properly Date and Label Food Items in Unit Kitchenettes
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple undated and improperly labeled food items found in two unit kitchenettes. During observations, surveyors identified several food containers and bags in the refrigerators that were either undated or not labeled with the required information, including resident names and dates. Items such as a green bag of food, a plastic container, a container of thickened water, and two 32-ounce containers of nutritionally fortified supplemental drinks were found opened but undated. Additionally, some items were found past the facility's stated discard timeframe, such as a bag dated 6/11/25 that had not been removed. Interviews with the Food Service Director (FSD) and a nurse revealed inconsistencies in the understanding and implementation of the facility's food storage policy. The FSD stated that nurses are responsible for labeling and dating food brought in by families before placing it in the kitchenette refrigerator, and that leftover food should be discarded after three days. However, a nurse indicated that all resident food items and leftovers should be dated and discarded after two days. Both agreed that open supplemental drinks should be dated. The facility's policy requires all perishable foods to be labeled with the resident's name and date and to be discarded after 48 hours, but these procedures were not consistently followed, leading to the deficiency.
Failure to Document Insulin Administration per Physician Order
Penalty
Summary
The facility failed to accurately document the administration of insulin lispro for one resident with diabetes and severe cognitive impairment. According to physician orders, the resident was to receive insulin lispro based on a sliding scale whenever blood sugar readings exceeded 200, with blood sugars checked three times daily. Review of the Medication Administration Record (MAR) for the specified period showed multiple instances where the resident's blood sugar was above 200, but there was no documentation that insulin lispro was administered as required. There was also no documentation of refusal or any rationale for not administering the insulin. Interviews with nursing staff and facility management confirmed that insulin administration should be documented at the time of administration, and that the resident did not refuse insulin. The DON acknowledged that the MAR was inaccurate and that the physician's order had been transcribed incorrectly as a PRN order, which failed to alert nurses to administer the insulin as scheduled. Subsequent statements from nursing staff indicated that insulin had been administered on the required occasions, but documentation was omitted.
Failure to Honor Resident's Shower Preference Due to Delayed Equipment Procurement
Penalty
Summary
The facility failed to honor a resident's personal care preferences by not providing showers as requested, instead only offering bed baths since the resident's admission. The resident, who was cognitively intact and dependent on staff for bathing due to right-sided hemiplegia following a stroke, repeatedly expressed a preference for showers, stating that bed baths were degrading and did not adequately clean their long hair. Family members also voiced concerns to staff and the resident's physician about the lack of showers and the use of dry shampoo, which left the resident's hair greasy and covered in residue. Despite the resident's care plan and care card indicating a need for staff assistance and a mechanical lift for shower transfers, documentation failed to show that any showers were provided. Staff interviews revealed that although safe shower chairs were available for residents with similar needs, the primary CNA and facility administration believed there was no appropriate shower chair for this resident. Occupational therapy records indicated that showering was a goal, but the resident was dependent and unsafe for showers without specialized equipment. The occupational therapist reported notifying her supervisor months prior about the need for a suitable chair, and a new chair was only recently obtained but not yet evaluated for use. Further interviews with facility leadership confirmed awareness of the resident's unmet preference and acknowledged significant delays in ordering and modifying the necessary shower chair. The Regional Director of Rehab admitted that the process to research, order, and modify the chair took several months longer than acceptable, resulting in the resident being denied showers for an extended period. The DON stated that all residents should be able to choose between a bath or shower and that equipment should be obtained in a timely manner, but was unaware of the timeline for this request.
Failure to Initiate Timely Occupational Therapy Referral for Contracture Management
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with upper extremity contractures. The resident, who had a history of stroke, traumatic brain injury, and dementia, was observed to have significant contractures in both upper extremities. The resident was unable to communicate effectively and was noted to have impaired range of motion, with both hands closed and arms held closely to the chest. The care plan and multiple assessments documented the presence of contractures and the need for monitoring changes in functional abilities. On a specific date, the nurse practitioner (NP) documented a recommendation for an occupational therapy (OT) referral to address the resident's worsening contractures. However, there was no evidence that an order for OT services was placed in the medical record following this recommendation. Interviews with facility staff, including the Director of Rehab (DOR), OT, and DON, revealed that the referral process was not followed, and the OT was not made aware of the NP's recommendation until the issue was brought up by a surveyor. The facility's policy required that therapy referrals be evaluated within 48 hours, but the resident was not evaluated by OT until 49 days after the NP's recommendation. Documentation failed to show that a paper referral form was completed or that any contraindications for therapy were documented. Staff interviews indicated a lack of clarity and communication regarding the referral process, with the NP assuming therapy had begun and the DOR and OT unaware of the referral. As a result, the resident did not receive timely OT evaluation and intervention for contracture management as recommended by the NP and required by facility policy.
Failure to Date Opened Medications with Shortened Expiry
Penalty
Summary
Surveyors observed that staff failed to store drugs and biologicals in accordance with State and Federal laws, specifically by not dating medications with shortened expiry dates once opened, as required by the facility's own policy. During an inspection of a medication cart, one fluticasone propionate and salmeterol inhaler, two incruse ellipta inhalers, and one lantus solostar insulin pen were found opened but undated. Interviews with the Unit Manager and the DON confirmed that these medications should have been dated upon opening due to their shortened expiry periods, but this was not done.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with accepted professional standards of practice. During a medication storage observation on the first-floor unit, a nurse left the medication cart unlocked and unattended while walking to the other end of the hallway. The nurse acknowledged that the cart should not have been left unlocked. Similarly, on the second-floor unit, another nurse left her medication cart unlocked and unattended while administering medications to a resident. Both nurses admitted that the carts should have been locked when not in use. Additionally, an unlocked treatment cart was observed on the first-floor unit with no licensed nurse in view. The cart contained prescription creams and was accessible to anyone passing by. The unit manager and another nurse confirmed that the treatment cart should have been locked when unattended. The Corporate Director and the Director of Nursing reiterated that medication and treatment carts should be locked when not within the nurse's view.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that transmission-based precautions were followed to prevent the spread of infections. Specifically, a nurse did not appropriately don a precaution gown while caring for a resident on enhanced barrier precautions (EBP). The facility's policy on Enhanced Barrier Precautions for Multidrug-Resistant Organisms (MDROs) requires the use of gowns and gloves during high-contact resident care activities, such as wound care, for residents with open wounds requiring dressing changes. Despite this policy, Unit Manager #1 was observed not wearing a precaution gown while removing a dressing from a resident's right lateral foot, which had a pressure ulcer wound. The incident was confirmed through interviews with various staff members, including a Certified Nurse Assistant (CNA), the Corporate Director, and the Director of Nursing (DON). All acknowledged that a precaution gown should have been worn in addition to gloves when handling the resident's wound, as the resident was on EBP. The failure to adhere to the facility's infection control policy was evident when Unit Manager #1 only wore gloves and not a gown during the wound care procedure, despite the presence of signage indicating the need for both gloves and a gown.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident who was admitted with diagnoses including dementia and psychosis. The resident was found with a bruise of unknown origin on the left side of the face, which was not immediately reported to the Director of Nursing (DON) or the Administrator as required by the facility's policy. The policy mandates that any incident meeting the criteria of a reportable incident, such as alleged physical abuse, should be immediately reported to the DON and Administrator. However, the nursing staff did not notify the administration about the bruise, leading to a delay in reporting the incident to the state agency. The incident was first noted by a nurse on duty, who did not recall seeing the bruise and did not report it to the DON. Another nurse, who worked the following shift, also noticed the bruise but did not notify the administration. It was only after the DON read the nursing note that the administration became aware of the bruise, which was then reported to the state agency 30 hours after the staff first became aware of it. The Administrator confirmed that the direct care staff should have reported the injury of unknown origin to the administration, but this did not occur, resulting in a breach of the facility's abuse prohibition policy.
Failure to Update Care Plan for Resident's Independence
Penalty
Summary
The facility failed to ensure that care plans were reviewed and updated by the interdisciplinary team as required, specifically for one resident. This resident, admitted in November 2022 with a diagnosis of irritable bowel syndrome, was assessed as cognitively intact with a BIMS score of 15 out of 15. The Minimum Data Set (MDS) assessment dated February 7, 2024, indicated that the resident was independent in oral hygiene, toileting hygiene, and toilet transfer. However, the resident's care plan, last revised on various dates in 2023 and January 2024, did not reflect these independent capabilities and instead indicated the need for assistance in these areas. The care plan's failure to be updated was confirmed through a review of the resident's ADL flow sheets from February 2024, which consistently coded the resident as independent in oral hygiene, toileting hygiene, and toilet transfer. During an interview, the Director of Nursing acknowledged that the interdisciplinary team responsible for completing section GG under the MDS should have updated the care plan following the comprehensive assessment on February 7, 2024, but this was not done.
Failure to Apply Offloading Booties as Ordered
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not adhering to physician's orders regarding the application of offloading booties to the resident's heels while in bed. The resident, who was admitted with diagnoses including adult failure to thrive and repeated falls, was at risk for pressure ulcers as indicated in their Minimum Data Set (MDS) assessment. Despite the physician's order dated 5/31/24 to apply booties to the resident's bilateral heels while in bed, observations on multiple occasions revealed the resident lying in bed with their heels directly on the mattress, and the booties were found across the room. Interviews with facility staff, including a Certified Nurse Assistant (CNA) and a nurse, confirmed that the resident should have been wearing the offloading booties while in bed and that the resident did not refuse to wear them. The Treatment Administration Record (TAR) inaccurately documented that the booties were applied as ordered, and there was no record of the resident refusing the booties. The Director of Nursing (DON) also confirmed that the booties should have been worn according to the physician's order, and any refusal would have been documented in the TAR or a progress note.
Failure to Ensure Correct Catheter Size for Resident
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident. Specifically, the staff did not ensure the correct size suprapubic indwelling urinary catheter was in place as ordered by the physician. The resident, who was admitted with diagnoses including Parkinson's disease, urine retention, and legal blindness, was observed with a 16 French catheter with a 5 cc balloon, contrary to the physician's order for a 16 French 10 cc catheter. The facility's policy requires verification of the correct catheter size before insertion, but this was not adhered to. Interviews with staff revealed that the catheter was changed on a previous date due to leakage, but the correct size was not used. The resident confirmed that the catheter was not changed on the date specified in the physician's order and expressed a preference for changes every four to six weeks. The Director of Nursing acknowledged that the physician's order should have been implemented, indicating a lapse in following the prescribed medical orders for catheter care.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube), as the amount of tube feeding infused did not match the physician's orders. The resident, who was admitted with diagnoses including stroke, dementia, dysphagia, and PTSD, had an active physician's order for Jevity 1.5 calorie to be administered via pump at 60 mL per hour, with specific instructions to hold and resume feeding at designated times. However, observations revealed that the tube feeding was not infusing as ordered, with the 1500 mL bottle of Jevity remaining unchanged throughout the day. The issue was compounded by a defect in the feeding machine, which was not identified until later in the day. Nurse #7, who was responsible for the resident's care, admitted to not routinely checking the enteral feeding during her shift and was unaware of any staff pausing or turning off the machine. The Director of Nursing expected the tube feeding to be assessed and monitored, and was aware of the physician's concerns about the feeding being stopped. Despite these expectations, the deficiency occurred, leading to the resident not receiving the prescribed amount of nutrition.
Failure to Implement Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD), stroke, dysphagia, and malnutrition. The resident, who had moderate cognitive impairment, was observed receiving oxygen at a flow rate of three liters per minute, contrary to the physician's order of two liters per minute via nasal cannula continuously. This discrepancy was noted during multiple observations by the surveyor. The facility's policy on oxygen therapy requires a physician's order to initiate oxygen therapy, and the resident's care plan indicated that oxygen should be administered continuously as ordered. Despite this, the resident's oxygen was set incorrectly, and the Director of Nursing confirmed the error upon observation. Interviews with nursing staff revealed that the resident does not adjust the oxygen settings, indicating that the staff failed to implement the physician's order correctly.
Failure to Complete Significant Change of Status MDS
Penalty
Summary
The facility failed to adequately identify and assess a significant change in condition for a resident, leading to a deficiency. The resident, admitted in February 2019 with chronic obstructive pulmonary disease (COPD), stroke, dysphagia, and malnutrition, experienced significant weight loss and a decline in mobility. The resident's weight dropped from 129 pounds to 109 pounds, indicating a significant weight loss of over 12% in 30 days. Additionally, the resident's ability to transfer from bed to chair deteriorated from requiring supervision to being totally dependent on staff. Despite these changes, the facility did not complete a Significant Change of Status Minimum Data Set (MDS) assessment within the required 14-day period following the determination of the significant change. The Director of Nursing acknowledged that a Significant Change of Status MDS should have been completed. The MDS Nurse responsible for this task was unavailable for an interview as she no longer worked at the facility.
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 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.
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.
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.
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.
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 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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