Cape Cod Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Brewster, Massachusetts.
- Location
- 383 South Orleans Road, Brewster, Massachusetts 02631
- CMS Provider Number
- 225667
- Inspections on file
- 28
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cape Cod Post Acute Care during CMS and state inspections, most recent first.
Two residents experienced deficiencies when professional standards were not followed, including the addition of a schizophrenia diagnosis without supporting documentation, repeated missed doses of prescribed ophthalmic ointment without proper physician notification or documentation, and failure to complete a required AIMS assessment for tardive dyskinesia after agreement by the physician. Staff interviews confirmed gaps in documentation, communication, and adherence to clinical recommendations.
Staff failed to properly store and secure medications, including leaving an open drink in a medication freezer and leaving medications unattended on a medication cart and at a resident's bedside during a med pass. Nursing staff acknowledged that these actions were not in line with facility policy and safe medication practices.
The facility did not complete or document required contact tracing and outbreak testing after two residents with severe cognitive impairment tested positive for COVID-19. Staff were unable to identify who was exposed or when exposed individuals were tested, and the available testing log was incomplete, indicating that infection control policies were not followed.
The facility did not consistently provide education, assess eligibility, offer, or document administration of pneumococcal vaccines in line with CDC recommendations for four residents. Some residents were not re-offered the current recommended vaccines after refusing older versions, while others had no record of being offered the vaccine at all. Staff interviews revealed confusion about responsibility for vaccine coordination and incomplete documentation in the electronic medical record.
The facility did not consistently provide education, assess eligibility, offer, or document the administration of the current COVID-19 vaccine for several residents, including those with cognitive impairment and complex medical histories. Staff interviews revealed uncertainty about who was responsible for vaccine coordination, and electronic records were incomplete or missing key information about vaccine offers and administration.
A resident with advanced COPD and CHF, on hospice care and dependent on oxygen and CPAP, was observed in respiratory distress with labored breathing and bluish skin. Despite being alerted, a nurse failed to perform a full assessment or promptly intervene, instead leaving the resident to continue medication administration for others. The hospice nurse later found the resident with low oxygen saturation and significant respiratory compromise, and facility policy requiring thorough assessment and documentation was not followed.
A resident with PTSD and moderate cognitive impairment was admitted without a trauma assessment to identify potential triggers, and the care plan did not include individualized trauma-related interventions. Staff interviews confirmed that required trauma evaluations were not completed on admission or during quarterly reviews, and the health care proxy was not consulted despite the resident's cognitive limitations.
Surveyors found multiple instances of improper food storage and labeling in the kitchen refrigerator, including undated, uncovered, and expired food items, as well as visible spoilage and exposed products. The Food Service Manager confirmed these practices did not follow facility policy or professional standards, increasing the risk of foodborne illness for high-risk residents.
A resident with complex medical needs and requiring staff assistance for ADLs had multiple instances of incomplete CNA documentation in the electronic health record over several months. Despite facility policy and expectations that all ADL care be documented by the end of each shift, numerous days were found where ADL care areas were left blank across all shifts, as confirmed by staff interviews.
A resident in an LTC facility, who was on hospice care and experiencing a decline in condition, did not have complete and accurate documentation in their medical records. Despite the facility's policies requiring documentation of changes in condition and RN pronouncement, there were gaps in the nursing progress notes. Interviews revealed that nurses either did not document due to time constraints, lack of instruction, or perceived it unnecessary for a dying resident. The DON confirmed that the facility's policy was not followed.
A facility failed to maintain accurate TARs in the EMR for a resident with orders for wound dressing changes. The resident had multiple diagnoses, including pressure ulcers, and required daily dressing changes. Documentation was missing for several treatments in May and June, indicating they may not have been provided. Interviews with nursing staff confirmed that blank TAR entries meant treatments were likely not done, as expected by the Unit Manager and DON.
A resident with a history of dementia and other conditions was found with facial bruising and swelling. The incident was reported to the DON on the same day but was not reported to the DPH until the following day, violating the Facility's policy requiring immediate notification within two hours.
The facility did not notify the physician about significant weight changes in two residents, leading to a deficiency in care. One resident experienced a weight loss of 12.66% over three months and 5.39% in one month, while another had a weight loss of 6.95% in one month and 10.54% over three months. Despite the facility's policy requiring physician notification for such changes, this was not done. Interviews with staff, including a nurse, unit manager, registered dietitian (RD), and director of nursing (DON), revealed gaps in communication and accountability regarding the notification process.
The facility did not ensure a safe environment for residents with a history of falls and cognitive impairments, leading to multiple falls and injuries. One resident with a history of strokes and cognitive deficits experienced six falls, including rib fractures and a head injury, without adequate supervision or interventions. Another resident with severe cognitive impairment and a history of falls had four falls, one resulting in a hip fracture requiring surgery, without updates to care plans or new interventions. Incident reports and post-fall evaluations were not completed promptly, and care plans were not updated to reflect new fall risks, contributing to the deficiencies.
Two residents experienced significant weight loss that went unmonitored and unaddressed. One resident with schizoaffective disorder and type II diabetes lost 12.66% of their weight in three months and an additional 5.39% in one month, despite being on a specific diet and having weekly weight orders. The facility did not notify the physician or dietitian of these changes. Another resident with hypertension, atrial fibrillation, and cerebral infarction lost 10.74% of their weight over three months. This resident was on a mechanically altered diet and house supplement regimen, but the facility did not document the percentage of supplements consumed and lacked monthly weight orders, leading to insufficient monitoring and intervention.
The facility failed to develop and implement individualized care plans for nine residents, leading to issues such as pressure ulcers, falls, lack of activity engagement, and inadequate meal supervision. Specific deficiencies included a resident developing a full-thickness unstageable heel ulcer, another resident walking independently post-hip surgery without a fall prevention plan, and a high-risk aspiration resident left unsupervised during meals.
A facility failed to provide appropriate care and treatment for a resident's pressure ulcer, leading to the development and worsening of an unstageable left heel ulcer. The facility did not conduct timely assessments, develop a comprehensive care plan, or implement wound care treatments as recommended by the wound physician. Weekly skin assessments and prescribed treatments were inconsistently applied, contributing to the resident's ongoing pain and ulcer deterioration.
The facility failed to provide structured and individualized activities for residents, including during an infectious outbreak, for those on the secure unit, and for short-term rehabilitation residents. Specific residents were not engaged in activities matching their interests, and activity staff lacked experience and did not conduct necessary assessments or care plans.
The facility failed to ensure the activity program was directed by a qualified professional. The Administrator confirmed the absence of an Activity Director, and interviews with three Activity Assistants revealed they had no prior experience or responsibility for resident activity assessments or care plans.
The facility failed to conduct a comprehensive facility-wide assessment and did not consistently implement an accurate nursing staffing pattern, leading to unsafe conditions where nurses were left to care for more than 40 residents alone. Additionally, the facility assessment tool did not accurately reflect the needs of residents requiring specialized treatments, and the facility lacked a full-time Activities Director since November 2023.
The facility failed to provide a dignified and homelike dining experience for residents in the North Two Unit dining room. Observations showed inconsistent meal service, with some residents waiting up to 25 minutes for their meals and all meals being served on trays. Staff interviews confirmed that the meal delivery system was flawed, leading to residents being served at different times.
The facility failed to document and address grievances from the Resident Council in a timely manner. Missing meeting minutes and unresolved concerns, such as long call light wait times and requests for more activities, indicate a lapse in adherence to policies.
The facility failed to follow professional standards of practice for six residents, including not completing a physical therapy evaluation, not obtaining and recording weights as ordered, not using Geri-sleeves as prescribed, not scheduling a urology follow-up, and not completing necessary documentation and assessments after falls.
The facility failed to follow food safety and sanitation standards, leading to potential foodborne illness risks. Observations revealed improper labeling and dating of food products, unclean equipment in nourishment kitchenettes, and improper hand hygiene during food handling. Additionally, resident food items were improperly labeled and stored in a medication refrigerator. The Food Service Director, Director of Maintenance, and Administrator acknowledged these deficiencies.
The facility failed to maintain an infection prevention and control program, including not implementing required COVID-19 testing for staff and residents, not adhering to PPE protocols, and not maintaining accurate infection surveillance records.
A resident with atrial fibrillation and emphysema was observed self-administering inhalers without proper authorization or assessment. The facility's policy required locked storage and periodic assessments, which were not followed. Staff interviews revealed a lack of awareness and adherence to the policy, resulting in the resident self-administering medications unsafely.
The facility failed to ensure that a resident was assessed for a less restrictive device based on medical symptoms. The resident, diagnosed with dementia and major depressive disorder, was observed with a velcro alarm seatbelt in a wheelchair, which they could not remove, indicating it was a restraint. The facility's policy requires restraints to be used only when less restrictive interventions are ineffective and must be based on a comprehensive assessment, which was not adequately documented. Staff interviews and medical records revealed inconsistent documentation and lack of attempts to use less restrictive alternatives.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents. One resident did not receive a written summary of the care plan, and another did not have a care plan for urinary retention and catheterization initiated upon admission. Interviews confirmed these deficiencies.
The facility failed to review and update the fall care plan for a resident with severe cognitive impairment after each MDS assessment, despite the resident experiencing multiple falls. Staff interviews revealed confusion about responsibility for care plan updates, and the care plan did not reflect necessary interventions post-fall.
A facility failed to provide appropriate care for a resident with a left-hand contracture, leading to a decline in the resident's condition. Despite a physician's order to wear a splint daily, the resident reported that the splint was broken and had not been worn for one to two months. Nursing staff were aware but did not take action or notify the rehabilitation department. The resident's condition worsened, and an OT evaluation confirmed the need for a new orthotic device and OT services.
The facility failed to ensure proper catheterization and follow-up care for a resident with urinary retention. The resident did not receive necessary education, competency training, or timely care plan development, and no follow-up urology appointment was arranged. Staff interviews revealed a lack of documentation and oversight in the resident's self-catheterization process.
A facility failed to maintain sanitary conditions of oxygen tubing and equipment and did not administer the oxygen flow rate per physician's orders for a resident with chronic respiratory failure and COPD. The resident was observed adjusting the oxygen flow rate independently, and the care plan did not address this behavior. The Director of Nursing confirmed that the equipment maintenance and oxygen administration were not in compliance with professional standards.
The facility failed to ensure proper dialysis care and communication for a resident by not providing a Dialysis Communication Book, not documenting pre- and post-dialysis vital signs, and not monitoring the AV fistula for thrill and bruit. Staff interviews and medical record reviews confirmed these deficiencies.
The facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and did not address pharmacy consultant recommendations timely for a resident on antipsychotic therapy. The required AIMS assessment was not completed for 14 months, contrary to the facility's policy.
The facility failed to properly label opened medications and secure the North 1 medication storage room. An opened bottle of Atropine sulfate ophthalmic solution and an opened bottle of Fluticasone propionate nasal spray were found without proper labeling. Additionally, the North 1 medication storage room was observed open and unattended on two occasions, allowing free access to medications.
A resident with a documented allergy to strawberries repeatedly received strawberry jam on his/her breakfast tray despite the allergy being noted in medical records and care plans. The issue persisted despite discussions with the food service director, indicating a failure in the facility's food service process.
The facility failed to coordinate with the hospice provider to maintain complete medical records for two residents, resulting in missing documentation and incomplete records, which hindered effective communication and continuity of care.
The facility failed to educate a resident on the benefits and side effects of immunizations, did not offer the influenza and pneumococcal vaccines, and did not document consent or refusal. The Infection Preventionist did not track vaccines or follow up on incomplete consent forms, leading to a lack of documentation in the resident's medical records.
The facility failed to educate, offer, and administer the COVID-19 vaccine to a resident, despite having a signed consent from the Health Care Proxy. The Infection Preventionist did not track vaccine administration, leading to a six-week delay without proper documentation or follow-up.
The facility failed to complete an accurate MDS assessment for a resident, omitting the BIMS assessment and incorrectly indicating the presence of an indwelling catheter. The resident was admitted with urinary retention and chronic kidney disease, and the inaccuracies were confirmed by the MDS nurse.
The facility failed to include mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for all staff members. A review of staff education records showed that 11 sampled staff, including nurses and CNAs, did not receive this training. The Staff Development Coordinator confirmed that QAPI education was not part of the orientation or yearly in-service training.
Failure to Adhere to Professional Standards in Diagnosis Documentation, Medication Administration, and Clinical Assessments
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for two residents, resulting in deficiencies related to documentation, medication administration, and adherence to clinical recommendations. For one resident, a diagnosis of schizophrenia was added to the medical record more than two years after admission without any supporting documentation or evidence from historical medical providers. The medical record did not indicate the presence of this diagnosis at admission, and staff interviews confirmed that no one could identify the source or justification for the diagnosis. Additionally, there was no care plan developed for schizophrenia, and efforts to locate supporting documentation were unsuccessful. In the same case, the resident was prescribed sodium chloride 5% ophthalmic ointment for eye health, but the medication was not administered on multiple occasions over several months. The medication administration record showed repeated missed doses, and there was no documentation explaining why the medication was not given or whether the physician was notified about its unavailability. Staff interviews revealed confusion regarding whether the medication should be supplied by the pharmacy or central supply, and it was confirmed that the required notifications and documentation were not completed when the medication was unavailable. For another resident, the facility did not follow through on a pharmacy and physician recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for tardive dyskinesia, despite the resident receiving antipsychotic medication. The recommendation was agreed to by the physician, but the assessment was not performed, and there was no evidence in the medical record that the AIMS had been completed. Staff interviews confirmed that the process for carrying out and documenting pharmacy recommendations was not followed in this instance.
Failure to Properly Store and Secure Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as evidenced by two specific incidents. In one medication room, an open drink labeled as a Coolata with a straw was found stored inside the medication freezer. The nurse present acknowledged that food and drinks are not supposed to be stored in the medication refrigerator or freezer and stated that the drink belonged to him and should have been kept in the employee break room. The Director of Nursing confirmed that no food or drink should ever be stored in the medication refrigerator or freezer due to the risk of cross-contamination. Additionally, during a medication pass, a nurse prepared multiple medications for a resident, including pills, an inhaler, and ointment. The nurse placed the inhaler and ointment on top of the medication cart and took the medication cups into the resident's room, leaving the other medications unsecured on the cart. When the nurse needed a larger blood pressure cuff, she left the medication cups unattended on the resident's overbed table and left the cart with medications on top, both unsecured and unattended. Another nurse later acknowledged that medications should not have been left at the bedside or on top of the cart, as it was not safe.
Failure to Complete Contact Tracing and Outbreak Testing for COVID-19 Cases
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required, specifically by not completing contact tracing and outbreak testing for two residents who tested positive for COVID-19 in February 2025. Facility policies required identification of exposed individuals, documentation of contacts, and outbreak testing every 48 hours for those exposed, but these procedures were not followed. The facility was unable to provide documentation of who had been exposed to the infected residents or when exposed individuals were tested, and the available COVID-19 testing log was incomplete and did not clarify whether the tests performed were related to the outbreak or were precautionary. Both affected residents had severe cognitive impairment and were symptomatic at the time of their positive COVID-19 tests. Interviews with the DON/Infection Preventionist and consulting staff confirmed that contact tracing and outbreak testing should have been conducted and documented, but they were unable to produce the required records or logs. The lack of documentation and incomplete testing logs indicated that the facility did not follow its own policies or CDC guidelines for managing COVID-19 outbreaks, resulting in a failure to prevent potential transmission of communicable diseases.
Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and administer pneumococcal vaccinations according to CDC recommendations for four out of five residents reviewed for immunizations. Facility policy required that all residents be offered vaccines unless medically contraindicated, and that education and information be provided prior to vaccination. However, review of medical records and immunization documentation revealed that several residents either were not offered the current recommended pneumococcal vaccines (PCV20 or PCV21), or there was no documentation of such offers, consents, or refusals. One resident with moderate cognitive impairment had consented to receive the pneumococcal vaccine but later refused the older PCV13 vaccine, and there was no evidence that the current vaccine was re-offered. Another resident, who was cognitively intact, had no record of being offered, accepting, or refusing the pneumococcal vaccine. A third resident with severe cognitive impairment had refused the older PPSV23 vaccine, but there was no documentation that the current vaccine was offered to the resident or their representative. A fourth resident with severe cognitive impairment had documentation of a previous pneumococcal vaccine but lacked details on which vaccine was given and when, and there was no record of being offered the current vaccine. Interviews with nursing and administrative staff revealed uncertainty about who was responsible for coordinating vaccine consents and administration, especially after the departure of the Infection Preventionist. Staff were unable to locate additional consents or administration records, and there was a lack of clarity regarding oversight of the immunization process. This resulted in incomplete documentation and failure to ensure residents were appropriately assessed and offered the current pneumococcal vaccines as per CDC guidelines.
Failure to Provide, Offer, and Document COVID-19 Vaccination per CDC Guidance
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and properly document the administration of COVID-19 vaccinations in accordance with CDC recommendations and its own policies for five residents. The facility's policies require that all residents be offered vaccines unless medically contraindicated, that education be provided prior to vaccination, and that all actions be documented in the medical record. However, record reviews revealed that for several residents, there was either no documentation of education, no record of the vaccine being offered, or incomplete records regarding vaccine administration and consent. For example, one resident's consent form indicated refusal due to already having received a vaccine, but the form was undated and lacked details about which vaccine was received or when. Another resident's record showed receipt of a previous season's vaccine but did not indicate whether the current vaccine was offered or accepted. In two cases, residents or their representatives signed forms indicating acceptance of the current vaccine, but there was no documentation that the vaccine was actually administered. Additionally, for some residents with severe cognitive impairment, there was no evidence that the vaccine was offered to their representatives or that any decision was documented. Interviews with staff revealed confusion regarding who was responsible for coordinating vaccine consents and administration, especially following the abrupt departure of the Infection Preventionist. Staff were unable to locate administration records for residents who had signed consent forms and were unsure if the vaccine had been offered to all eligible residents. The electronic immunization records were often incomplete or blank, further indicating a lack of proper documentation and follow-through on vaccination protocols.
Failure to Assess and Respond to Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when staff failed to fully assess and promptly treat a resident who was observed to be in respiratory distress. The resident, who had a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and respiratory failure, was on hospice care and dependent on oxygen and CPAP therapy. On the morning of the incident, the resident was found sitting on the edge of the bed, appearing bluish/gray, with labored, rapid breathing and grunting sounds, while holding a CPAP mask and receiving oxygen via nasal cannula at 3 liters per minute. Despite being alerted by both a CNA and another resident, the nurse did not perform a full assessment or take vital signs, and instead left the room to notify the DON and continued with medication administration for other residents. The nurse did not return to the resident's room until after a hospice nurse had already entered and begun assessing the resident. The hospice nurse found the resident to have significant dyspnea, diminished lung sounds with crackles, and an oxygen saturation of 85%. She recommended increasing oxygen flow and inquired about the last administration of Morphine for comfort. The nurse reported that Morphine had last been given several hours earlier and that the resident had refused a subsequent dose. The nurse then increased the oxygen flow and applied the CPAP mask, but documentation of a comprehensive respiratory assessment was lacking in the medical record. Facility policies required prompt notification of changes in condition, thorough assessment including vital signs and respiratory evaluation, and documentation of findings and interventions. Interviews with the DON and consulting staff confirmed that the nurse did not follow proper procedures for assessing and responding to a change in condition. The nurse acknowledged not taking a complete set of vital signs and stated that the presence of a surveyor made him nervous, contributing to the incomplete assessment and delay in care.
Failure to Assess and Care Plan for Trauma History in Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history of a resident with a diagnosis of PTSD, insomnia, REM sleep behavior disorder, depression, psychotic disorder, and anxiety. Upon admission, there was no evidence in the medical record that a trauma assessment was completed to identify potential triggers, despite facility policy requiring universal screening and individualized care planning for trauma survivors. The comprehensive care plan referenced the resident's PTSD and included general interventions, but did not specify any individualized triggers related to the resident's trauma history. Interviews with facility staff revealed that the social worker did not complete the required trauma evaluation on admission or during subsequent quarterly assessments, even though the resident had a known diagnosis of PTSD. The social worker acknowledged that the evaluation should have been conducted and, given the resident's cognitive impairment, should have involved the health care proxy, but this was not done. The DON confirmed that trauma evaluations and identification of triggers should be completed for all residents, especially those with PTSD, but was unsure why it was not done in this case.
Improper Food Storage and Labeling in Kitchen Refrigerator
Penalty
Summary
Surveyors observed multiple failures in food storage and labeling practices within the facility's main kitchen walk-in refrigerator. Items such as whipped cream, coleslaw, chopped spinach, turkey sandwiches, soups, roasted red peppers, chopped lettuce, sliced tomatoes, cilantro, shredded carrots, frozen meat, shredded lettuce, cinnamon rolls, bacon, and sausage were found either undated, improperly covered, or exposed. Several items were past their use-by or best-by dates, and some displayed visible signs of spoilage, such as brown discoloration, sogginess, limpness, and dried-out or exposed surfaces. The facility's own policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, with refrigerated foods monitored to ensure use by their expiration dates. The FDA Food Code also mandates date marking for ready-to-eat, time/temperature control for safety foods, and proper storage to prevent contamination. Despite these requirements, surveyors repeatedly found food items that were not labeled with open or use-by dates, not stored in their original containers, and not covered to prevent contamination. Some items, such as whipped cream pouches and exposed meats, were left uncovered, increasing the risk of cross-contamination. During interviews, the Food Service Manager confirmed that these practices did not align with facility policy or professional standards. The manager acknowledged that prepared foods should be stored in manufacturers' containers, labeled with open dates, and covered to prevent contamination. The manager also stated that all foods must be rotated and used or discarded by their expiration dates, and that exposed meats and other items should be kept covered. These lapses in food safety and sanitation practices created the potential for the spread of foodborne illness among residents, who are considered high risk.
Incomplete CNA Documentation of ADL Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required physical assistance with activities of daily living (ADLs). Review of the resident's CNA ADL Flow Sheets over a three-month period revealed multiple instances where documentation was left incomplete or blank across all three shifts. Specifically, there were numerous days in each month where ADL care areas were not documented by CNAs, despite facility policy requiring that all care provided be recorded in the electronic health record by the end of each shift. Interviews with CNAs and the Director of Nursing confirmed that it is the facility's expectation for CNAs to document all ADL care in the electronic medical record by the end of their shift, and that documentation should not be left incomplete. The resident involved had significant medical needs, including acute and chronic respiratory failure, myotonic muscular dystrophy, and required staff assistance for multiple ADLs as indicated in their care plan and MDS assessment. Despite these needs and clear policy, documentation lapses occurred repeatedly.
Failure to Document Resident's Decline and RN Pronouncement
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records of a resident who was experiencing a decline in condition, was on comfort measures at the end of life, and receiving hospice services. The facility's policies required that all services provided, changes in medical or mental condition, and incidents be documented in the resident's medical record. However, there was no documentation after a certain date to support that nursing staff had assessed and monitored the resident's decline in condition up to and including their death, or that an RN pronouncement had been completed. The resident, who had multiple diagnoses including cerebral palsy and unstageable pressure ulcers, was noted to be declining and was on hospice care. Despite the resident's condition requiring frequent pain management and interventions for excessive secretions, there were gaps in the nursing progress notes. Interviews with several nurses revealed that they either did not document the resident's condition due to time constraints, lack of instruction, or because they believed it was unnecessary for a dying resident. The Director of Nurses (DON) stated that it was expected for nurses to document a detailed assessment of a resident's change in condition every shift, especially when a resident is actively dying. The DON acknowledged that the facility's policy was not followed, as there were no nurse progress notes documenting the RN pronouncement or the resident's condition after a certain date. This lack of documentation was inconsistent with the facility's policies on change in condition and RN pronouncement.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate Treatment Administration Records (TAR) in the Electronic Medical Record (EMR) for a resident with physician orders for wound dressing changes. The resident, admitted in May 2024, had multiple diagnoses including a displaced condyle fracture, bilateral hearing loss, malnutrition, cerebral palsy, hypertension, and unstageable pressure ulcers on both hips. The facility's policy required detailed documentation of all treatments, including wound care, but this was not consistently followed. In May 2024, the resident had a physician order for daily dressing changes on a left hip pressure injury, which were not documented as administered on several occasions. Similarly, in June 2024, there were missing documentation entries for treatments on the resident's left distal calf and both hips, despite physician orders specifying daily care. Interviews with nursing staff revealed that if the TAR EMR was left blank, it indicated that the treatment was likely not provided, as confirmed by the nurses responsible for the resident's care. The Unit Manager and Director of Nursing (DON) both stated that it was expected for all treatments to be documented in the TAR EMR. They confirmed that if a treatment was not signed off, it was considered not done. This lack of documentation and potential omission of care highlights a deficiency in the facility's adherence to its own policies and professional standards for maintaining accurate medical records.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The Facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. On 4/08/24, a resident was found with facial bruising and swelling, which was reported to the Director of Nurses (DON) #1 on the same day. However, the incident was not reported to the DPH until the following day, 4/09/24, after the Administrator was informed. This delay in reporting is a violation of the Facility's policy, which mandates immediate notification to the appropriate State Agency within two hours of identifying an alleged or suspected incident. The resident involved had a medical history that included unspecified dementia, major depressive disorder, anxiety, hypertension, and unspecified psychosis. The resident's daughter was present when the discoloration was found and was very upset. Despite the immediate notification to the DON, the required report to the DPH was delayed, leading to a deficiency in timely reporting of suspected abuse, neglect, or injury of unknown origin as per the Facility's policy and state regulations.
Deficiency in Physician Notification for Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician about a change in condition for two residents, leading to a deficiency in care. For Resident #2, there was a significant weight loss of 12.66% in three months and 5.39% in one month, but the physician was not informed. Despite the facility's policy requiring notification of weight changes exceeding certain thresholds, the physician was not made aware of the resident's deteriorating condition. Similarly, for Resident #61, there were severe significant weight losses of 6.95% in one month and 10.54% in three months, yet the physician was not notified as per protocol. The failure to communicate these critical changes in residents' conditions to the physician resulted in a deficiency in care. In both cases, the facility's policy on weight assessment and interventions was not followed adequately. The policy outlined clear guidelines for monitoring weight changes, including the criteria for significant and severe weight loss, as well as the steps to be taken upon identifying such changes. Despite these guidelines, the facility did not ensure that the physicians were notified promptly about the residents' weight losses that exceeded the defined thresholds. This lack of adherence to established protocols contributed to the deficiency in care identified during the survey. During interviews with staff members, including Nurse #4, Unit Manager #1, Registered Dietitian (RD), and Director of Nurses (DON), it was revealed that there were gaps in communication and accountability regarding notifying the physician of significant weight changes in residents. While the RD reviewed weights and made recommendations, there was a lack of clarity on who was responsible for directly informing the physician about the identified weight losses. The interviews highlighted a need for improved communication processes within the interdisciplinary team to ensure timely and appropriate actions are taken in response to residents' changing conditions.
Fall Risk Management and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment for four residents (#24, #70, #226, and #2) leading to multiple falls and injuries. Resident #24, with a history of strokes and cognitive deficits, sustained six falls, including one resulting in rib fractures and a head injury. Despite the falls, the facility did not adequately supervise the resident or implement interventions to prevent further falls. Resident #70, with severe cognitive impairment and a history of falls, experienced four falls within a few months, one resulting in a hip fracture requiring surgical repair. The facility did not update care plans or implement new interventions to address the resident's fall risk, leading to repeated incidents. Furthermore, the facility failed to complete incident reports promptly and lacked proper documentation of falls and post-fall evaluations. For both residents, the facility did not conduct timely fall risk evaluations after incidents, did not update care plans with new interventions, and did not ensure proper supervision and assistance with activities like transfers and ambulation. The lack of adherence to fall prevention protocols and inadequate monitoring of residents' fall risks contributed to the deficiencies identified during the survey.
Nutritional Monitoring Deficiencies Identified in Residents with Significant Weight Loss
Penalty
Summary
The facility failed to monitor the nutritional status of two residents, Resident #2 and Resident #61, who experienced significant weight loss. For Resident #2, there was a severe significant weight loss of 12.66% in three months, followed by a continued significant weight loss of 5.39% in one month, which went unidentified and unaddressed by the facility. Resident #2, diagnosed with schizoaffective disorder and type II diabetes, required set-up assistance for meals and had a severe cognitive impairment. Despite being on a specific diet and having weekly weight orders, Resident #2's weight loss was not adequately monitored, and the facility failed to notify the physician or dietitian of the significant changes. Similarly, for Resident #61, there were multiple instances of severe significant weight loss over a three-month period, with a total weight loss of 10.74%. Resident #61, diagnosed with hypertension, atrial fibrillation, and cerebral infarction, required set-up feeding assistance and had a mechanically altered diet. Despite being on a house supplement regimen, the facility did not document the percentage value consumed by Resident #61 and failed to address the ongoing weight loss. The facility also lacked monthly weight orders for Resident #61, contributing to the lack of monitoring and intervention in response to the significant weight changes observed.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for nine residents, leading to various deficiencies in meeting their physical, psychosocial, and functional needs. For Resident #24, the facility did not create a care plan to prevent pressure ulcers, resulting in a full-thickness unstageable left heel ulcer. Additionally, the resident experienced six falls, one of which caused multiple rib fractures and a closed head injury, due to the lack of a comprehensive fall prevention care plan. The facility also failed to implement timely interventions recommended by a wound physician, such as the use of foam booties and heel elevation. Resident #226 did not have a care plan addressing fall prevention or the specific needs related to dialysis services. The resident was observed walking independently in the facility lobby after being dropped off by a bus driver, despite having undergone hip surgery and requiring assistance. The lack of a comprehensive care plan and fall risk evaluation upon admission contributed to this oversight. Similarly, Resident #49 did not have an activities care plan, despite expressing a desire to participate in activities like listening to music and engaging in art. Resident #14, who was at high risk for aspiration, did not receive the necessary supervision during meals. The resident struggled to eat independently, often spilling food and expressing frustration. Despite a care plan intervention for continual supervision during meals, staff frequently left the resident unattended, leading to potential risks of choking and aspiration. These deficiencies highlight the facility's failure to adhere to its policy of developing and implementing comprehensive, person-centered care plans for each resident.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and treatment to promote optimal wound healing and prevent the development of a facility-acquired unstageable left heel ulcer. The facility did not conduct a timely Braden risk assessment upon admission, complete an admission comprehensive skin assessment, develop and implement a care plan to address risk factors, obtain orders and provide wound care treatments per wound consultant recommendations, and consistently off-load the resident's heels and ensure weekly skin checks were completed per physician's orders. These failures led to the development and worsening of the resident's left heel ulcer, which was not properly documented or treated in a timely manner. The resident was admitted with diagnoses including encephalopathy, diabetes mellitus type 2, cognitive communication deficit, unsteadiness on feet, and lack of coordination. Despite being at risk for developing pressure ulcers, as indicated by the Minimum Data Set (MDS) assessment, the facility did not develop a comprehensive care plan for the prevention of skin breakdown and pressure injuries. The resident's left heel ulcer was first noted three weeks after admission, and the care plan for skin integrity was not developed until 1/12/24. The facility also failed to document and implement the wound physician's recommendations for treatment, including the use of Iodosorb gel and other dressings. Throughout the resident's stay, there were multiple instances where weekly skin assessments were not conducted, and the prescribed treatments were not consistently applied. The resident's left heel ulcer continued to worsen, and the facility did not follow the wound physician's recommendations for off-loading the heels and using foam booties. Interviews with staff revealed a lack of awareness and consistency in implementing the care plan and wound treatment recommendations. The facility's failure to provide timely and appropriate wound care contributed to the resident's ongoing pain and the deterioration of the left heel ulcer.
Failure to Provide Structured and Individualized Activities
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents across three nursing units. Specifically, the facility did not offer structured activities during an infectious outbreak, for residents on the secure unit, and for those admitted for short-term rehabilitation. The activity staff did not provide individualized activity programs for residents with specific needs and interests, such as Resident #44, who enjoyed fixing items, and Resident #69, who preferred religious services and group activities. Additionally, the facility did not assess and determine individualized activities for residents admitted for short-term rehabilitation, such as Resident #114, Resident #227, and Resident #24, nor did they ensure that residents like Resident #58 and Resident #94 were engaged in leisurely activities to enhance their quality of life within their cognitive abilities. The surveyors observed outdated activity calendars on bulletin boards and noted that activities were not being held due to a recent infectious outbreak. Activity staff were observed to be inexperienced and not conducting activity assessments, care plans, or notes. During the outbreak, group activities were halted, and only minimal individual activities, such as delivering coffee, were provided. The secure unit residents were left watching inappropriate television shows without staff supervision, and residents on the short-term rehabilitation unit were not assessed for their activity preferences. The facility lacked a policy for the provision of activities, and the activity staff did not meet with newly admitted residents to address their activity preferences. Specific residents were observed to be disengaged and not participating in activities that matched their interests. For example, Resident #44, who enjoyed fixing things, was found in a room with broken furniture and no constructive activities. Resident #69, who preferred religious services, was not brought to such activities. Resident #100, who enjoyed group activities, was often left alone in their room. The facility's failure to provide structured and individualized activities for these residents resulted in a lack of engagement and support for their physical, mental, and psychosocial well-being.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional from November 17, 2023, through the survey exit date of March 19, 2024. During the entrance conference on March 12, 2023, the Administrator confirmed that the facility did not have an Activity Director. Interviews with three Activity Assistants revealed that none of them had previous experience in activities or long-term care, and none were responsible for meeting with residents to determine activity preferences, completing assessments of activity needs, or creating care plans for residents. Activity Assistant #2 and #3 had started in January 2024 with no prior experience, and Activity Assistant #3 was transitioning to the laundry department. Activity Assistant #1, who started in 2019, was a part-time assistant with no oversight responsibilities for the activity department.
Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that accurately identified and implemented the necessary resources for both day-to-day and emergency care. Specifically, the facility did not consistently and accurately identify and implement their nursing staffing pattern for optimal resident care. The review of daily nurse staffing sheets and time card reports revealed multiple instances where the facility did not meet its own staffing requirements, leading to situations where nurses were left to care for more than 40 residents alone, which was acknowledged as unsafe by the Director of Nursing (DON) and the nursing staff interviewed. The facility's staffing issues were exacerbated by the recent loss of contracted travelers and the prohibition on using staffing agencies, leaving significant gaps in both nursing and CNA positions across various shifts. The facility's recruitment efforts were limited to advertising on a job recruitment website and word-of-mouth referrals, which were insufficient to address the staffing shortages. The Administrator admitted that the facility's staffing did not align with the facility assessment and recognized the insufficiency in meeting the required staffing levels. Additionally, the facility assessment tool failed to provide accurate information on the number of residents requiring specialized treatments such as IV medications, dialysis, and isolation or quarantine for active infectious diseases. The section on acuity did not reflect the actual needs of the resident population, and the Administrator acknowledged that this section needed revision. Furthermore, the facility failed to staff a full-time Activities Director since November 2023, leaving the activities program without designated oversight. The Administrator admitted that there had been insufficient staffing for activities, and there was no designated person responsible for the oversight of the activities program, which further contributed to the deficiency in providing comprehensive care to the residents.
Inconsistent Meal Service in Dining Room
Penalty
Summary
The facility failed to ensure a dignified and homelike dining experience for residents in the North Two Unit dining room. Observations revealed that meal service was inconsistent, with some residents receiving their meals significantly later than others. On multiple occasions, residents were served meals on trays, and there were delays between the arrival of the first and second lunch trucks, causing some residents to wait up to 25 minutes for their meals. This inconsistency led to situations where residents without meals were observed taking food items from other residents' trays, indicating a lack of coordination and timely service during mealtimes. Interviews with staff, including a CNA, a nurse, the Food Service Director, and the Regional Clinical Director, confirmed that the current meal delivery system was flawed. The staff acknowledged that the two trucks arriving at different times created a mix of residents being served at different times, which was not the intended process. The staff agreed that all residents in the dining room should be served simultaneously for a dignified dining experience and that meals should not be served on trays to maintain a homelike environment.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure grievances and concerns from the Resident Council were documented and acted upon timely, as required by their policy. During a survey, it was found that the facility did not have Resident Council meeting minutes for November and December 2023, and the minutes from January 2024 did not include follow-up on previous concerns. Residents reported that they had to repeat their concerns multiple times and felt that the Resident Council was ineffective in addressing their issues. Specific concerns included long call light wait times, delays in getting out of bed, and requests for more art supplies and in-house music activities, which were not adequately addressed or documented. The Administrator confirmed that the facility had not held a Resident Council meeting in February 2024 due to an infectious outbreak and that the Activity Director responsible for taking meeting minutes was no longer employed. The facility's failure to document and follow up on Resident Council concerns led to unresolved issues, such as long wait times for assistance and unmet requests for additional activities. The lack of documentation and timely response to grievances indicates a significant lapse in the facility's adherence to its own policies and procedures for Resident Council meetings.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for six residents, leading to multiple deficiencies. For one resident, the facility did not follow a physician's order to complete a physical therapy evaluation. The Rehabilitation Director was unaware of the order, and the resident did not receive the necessary therapy services until after the surveyor's intervention. Additionally, the facility's process for alerting the rehab staff about new orders was inadequate, contributing to the oversight. Another resident did not have their weight monitored as per physician's orders. The nursing staff failed to document the required weekly weight, and the dietitian noted that the current weight was pending. The facility's policy required weights to be recorded in the medical record, but this was not done, indicating a lapse in following professional standards. Similarly, another resident receiving hemodialysis did not have their post-dialysis weights recorded in the medical record, and the dialysis communication book was not properly maintained. The facility also failed to follow physician's orders for the use of Geri-sleeves for a resident, as the resident was observed multiple times without the sleeves, and the care plan did not reflect the requirement. Additionally, the facility did not schedule a urology follow-up appointment for a resident with urinary retention, despite it being noted in the discharge summary and physician's progress notes. Lastly, the facility did not complete incident reports, fall evaluations, neurological assessments, and post-fall notes for a resident who experienced multiple falls, failing to adhere to their fall prevention and management policy.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to follow their policy and professional standards of practice for food safety and sanitation, leading to potential foodborne illness risks for residents. Specifically, the facility did not properly label and date food products, and failed to maintain clean equipment in two nourishment kitchenettes. Observations revealed spilled liquids, food particle spatter, and dark brown stains inside microwaves, as well as white residue and rust stains on coffee pots. Additionally, cabinets underneath sinks were found with old and stained insect traps, dark brown/black stains, and old water stains. The space between cabinets and refrigerators had buildup, including black/blue residue, food residue, and insect traps. Refrigerators contained unlabeled and undated food items, contrary to facility policy requiring labeling with resident name, room number, item, date received, and discard date. The Food Service Director (FSD) and Director of Maintenance confirmed these findings and acknowledged the expectation for daily cleaning and proper labeling of food items. The facility also failed to handle ready-to-eat food using proper hand hygiene to prevent cross-contamination. During breakfast service, the cook was observed grabbing pancakes with gloved hands, touching condiment baskets, and returning to the food service line without changing gloves. The cook also touched carts and dirty pans before handling food again without changing gloves. Similarly, the FSD, while working the breakfast service line, opened a package of pancakes, placed them in the microwave, and returned to the service line without changing gloves. Both the FSD and the Administrator acknowledged that gloves should be changed when moving between equipment and the service line, and utensils should be used when handling food. Additionally, the facility improperly labeled and stored resident food items in a medication refrigerator on the Southwest Unit, which was not intended for food storage. Observations revealed various food items, including moldy sandwiches, expired yogurt, and unlabeled containers of food, stored in the refrigerator. Nurse #6 and the FSD confirmed that food should be labeled with the resident's name, date received, and discard date, and that the refrigerator was not monitored by kitchen staff. The Administrator acknowledged that the refrigerator was intended for medication storage only and that there was no oversight to ensure food was not stored there. The lack of proper labeling and storage of food items in the medication refrigerator posed a potential risk for foodborne illness.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Specifically, the facility did not implement COVID-19 testing every 48 hours for all staff and residents during a COVID-19 outbreak, as required by their policy, state, and national standards. The infection prevention specialist (IP) admitted to not tracking staff testing, and the Director of Nurses was also unsure of the tracking process. A review of the staff testing logs revealed that 11 out of 11 sampled staff members did not comply with the testing requirements, despite working numerous days during the outbreak period. Additionally, resident testing logs were incomplete or missing, indicating that testing was not conducted as required on certain units and days. The facility also failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use. Observations revealed that several residents who tested positive for COVID-19 did not have PPE supply carts or isolation signs at their room doors, despite having active physician orders for isolation precautions. In some cases, the isolation precautions were not maintained, and there were no physician orders to discontinue them. Staff interviews indicated confusion about which residents were on precautions and the proper use of PPE. Furthermore, the facility did not maintain an accurate line list for infection surveillance and tracking. A comparison of the line list and the COVID-19 positive log revealed discrepancies, with some residents appearing on one list but not the other. The infection surveillance line list also contained errors, such as culture dates being recorded before the date of symptom onset and conflicting symptoms in progress notes. Monthly data analysis reports for January and February were missing, and the IP was not available to provide further information. Consulting staff acknowledged the need for education and training for the IP on completing the line list accurately.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for one resident. The resident, who was admitted with diagnoses including atrial fibrillation and emphysema, was observed self-administering an Incruse Inhaler and an Albuterol Inhaler without proper authorization or assessment. The resident's Minimum Data Set (MDS) assessment indicated cognitive intactness, but there was no documentation of an assessment to determine the resident's ability to self-administer medications safely. During multiple observations, the resident was seen using and storing the inhalers in an unsecured manner. The resident confirmed that they self-administered the medications daily and kept a personal record of usage. However, the facility's policy required that self-administered medications be stored in a locked container and that an assessment be completed to ensure the resident's capability to self-administer medications. The resident's medical record lacked the necessary physician's orders and assessments for self-administration. Interviews with the nursing staff and management revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. The Unit Manager and Regional Clinical Director acknowledged that assessments and orders should have been in place, and the medications should have been stored securely. The facility's failure to follow its policy resulted in the resident self-administering medications without proper authorization and assessment, posing potential risks to the resident's safety.
Failure to Assess for Less Restrictive Device for Resident
Penalty
Summary
The facility failed to ensure that Resident #94 was assessed for a less restrictive device based on the resident's medical symptoms. The resident, who was admitted in May 2021 and diagnosed with unspecified dementia and major depressive disorder, was observed with a velcro alarm seatbelt in a high back wheelchair. The resident was unable to demonstrate how to remove the seatbelt, indicating it was a restraint. The facility's policy requires that restraints be used only when less restrictive interventions are ineffective and must be based on a comprehensive assessment, which was not adequately documented in this case. The resident's medical records and care plans did not provide sufficient documentation to justify the use of the restraint. The records showed inconsistent documentation of the resident's ability to release the seatbelt and lacked evidence of attempts to use less restrictive alternatives. Interviews with staff revealed that the resident was a mechanical lift for transfers and incapable of standing or self-transferring, further questioning the necessity of the seatbelt. The Director of Nurses and Unit Manager both acknowledged that the documentation did not meet policy guidelines and that the resident likely needed reassessment for the use of the seatbelt or a less restrictive device. Observations and interviews indicated that the resident did not exhibit behaviors that would necessitate the use of a restraint. The resident's behavior monitoring records showed no episodes of attempting to stand impulsively. The facility's failure to document the medical condition or symptoms warranting the restraint, along with the lack of attempts to use less restrictive alternatives, led to the deficiency. The facility's policy on restraint use was not followed, resulting in the inappropriate use of a restraint for Resident #94.
Failure to Develop and Implement Baseline Care Plans
Penalty
Summary
The facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of admission for two residents. For Resident #38, the facility did not provide a written summary of the baseline care plan by the completion of the comprehensive care plan and failed to document receipt of this information in the resident's clinical record. Despite being cognitively intact, Resident #38 reported not having a care plan meeting since admission and not receiving a copy of the baseline care plan. Interviews with social workers and consulting staff confirmed that the required care plan meeting and documentation were not completed as per facility policy. For Resident #108, the facility did not develop and implement a baseline care plan for the resident's urinary retention, indwelling Foley catheter, and need for straight catheterization upon admission. The Admission Nursing Evaluation indicated the need for catheterization, but no care plan was initiated until several months later. Interviews with multiple nursing staff and the MDS nurse revealed that the baseline care plan should have been developed at the time of admission but was not. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including initial goals, physician orders, therapy services, and social services. The policy also mandated providing the resident or their representative with a written summary of the baseline care plan and documenting receipt of this information. The facility failed to adhere to these policies for both residents, leading to deficiencies in care planning and documentation.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised by the interdisciplinary team (IDT) as required for one resident. Specifically, the facility did not review and update the fall care plan for a resident with severe cognitive impairment after each Minimum Data Set (MDS) assessment. The resident, who had a history of falls and required assistance for various activities, experienced two falls in the dining room. Despite these incidents, the care plan was not updated to reflect new interventions or assessments post-fall. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans and developing fall prevention interventions. The Unit Manager and Regional Clinical Director confirmed that care plans should have been updated after each fall, including immediate interventions to prevent further incidents. However, the care plan for the resident in question did not reflect these necessary updates, indicating a failure in the facility's adherence to its own policies on fall prevention and care plan management.
Failure to Provide Appropriate Care for Resident with Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a left-hand contracture, leading to a decline in the resident's condition. The resident, who was admitted in December 2020 with diagnoses including hemiplegia and hemiparesis affecting the left hand, had a physician's order to wear a splint daily. However, the resident reported that the splint was broken and had not been worn for one to two months. Despite informing the nursing staff about the issue, no action was taken to address the problem, and the resident's care plan did not include the use of the splint or the need for staff assistance in donning and doffing it. Observations and interviews revealed that the nursing staff were aware that the resident was not wearing the splint but did not notify the rehabilitation department or take steps to resolve the issue. Certified nurse assistants and a nurse confirmed that the resident chose not to wear the splint due to discomfort and that they had not seen the splint in use for a while. The unit manager and the director of nurses acknowledged that the policy and physician's order were not followed, and the resident should have been seen by occupational therapy (OT) for reevaluation. The resident's OT discharge summary from September 2023 indicated that the resident had made progress with the splint and was recommended to continue wearing it to prevent further contracture. However, the resident's condition worsened due to the lack of appropriate intervention. The OT evaluation conducted on March 15, 2024, confirmed that the resident's contracture had worsened and recommended a new orthotic device and OT services to address the issue.
Failure to Ensure Proper Catheterization and Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident was not catheterized unless required by their clinical condition to manage urinary continence/incontinence and prevent urinary tract infections (UTI). Specifically, the facility did not provide training and education on self-catheterization technique, did not evaluate and re-evaluate the resident's ability to self-catheterize, did not develop and implement a care plan in a timely manner, and did not make a follow-up appointment with a urologist as recommended. The resident was admitted with a diagnosis of urinary retention and was supposed to perform intermittent catheterization, but the facility did not document any education or competency training for the resident, nor did they develop a care plan until 107 days after admission. Additionally, the resident was hospitalized for complications related to self-catheterization, and no follow-up urology appointment was arranged as recommended. The facility's policies on incontinence management and catheter care were not followed, and there was no policy provided for intermittent catheterization or self-administration of treatments. The resident's medical record lacked documentation of education, competency training, and monitoring of the self-catheterization process. Interviews with staff revealed that there was no oversight or documentation of the resident's ability to perform the procedure independently, and the care plan was not initiated upon admission as required. The resident reported not receiving any education related to the procedure, hygiene, symptoms, or complications. Staff interviews indicated that the resident's self-catheterization process was not properly documented or monitored, and there was no evidence of a self-administration assessment or quarterly re-evaluations. The resident's care plan was delayed, and there was no documentation of a urology follow-up appointment. The Director of Nursing and Staff Development Coordinator were not available for interviews, and consulting staff confirmed that the resident's competency should have been documented and reviewed quarterly, but it was not. The facility's failure to follow policies and provide necessary education and monitoring led to the deficiency in care for the resident.
Failure to Maintain Sanitary Conditions and Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident with chronic respiratory failure and COPD. The oxygen tubing and equipment were not maintained in sanitary conditions, and the oxygen flow rate was not administered per physician's orders. Specifically, the oxygen tubing was observed resting on the floor, not dated or labeled, and not stored in a plastic bag to prevent contamination. The filter on the oxygen concentrator was laden with dust, and the resident was observed adjusting the oxygen flow rate independently, which was not addressed in the care plan or through documented education on compliance. During multiple observations, the resident was either not receiving oxygen as prescribed or using equipment that was not properly maintained. The Director of Nursing confirmed that the concentrator filters should be cleaned per physician's orders, the tubing should be changed weekly, dated, and stored properly, and the flow rate should be set per physician's orders and checked each shift. The resident's self-adjustment of the oxygen flow rate was not care planned, and there was no documentation of education provided to the resident regarding non-compliance.
Failure to Implement Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for a resident requiring dialysis. The facility did not provide ongoing communication between the nursing facility and the dialysis facility, nor did it consistently document assessments of the resident's condition and left AV fistula site. The facility's policy required the use of a Dialysis Communication Book to document pre-dialysis vital signs, medication administration, nutritional/fluid management, and any dialysis adverse reactions or complications. However, the resident reported that no such book was sent with them to dialysis, and staff interviews confirmed the absence of the book and its documentation. The medical record review revealed that the facility did not have a Dialysis Communication Book for the resident, and there was a lack of documentation for pre- and post-dialysis vital signs, treatment tolerance, and any new orders for resident care. Additionally, the facility failed to document the monitoring of the resident's AV fistula for thrill and bruit, as required by the facility's policy. The Treatment Administration Record (TAR) showed multiple instances where the dialysis access site dressing was not monitored for redness or bleeding, and there was no documentation of thrill and bruit monitoring. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not consistently monitor and document the resident's dialysis care. The facility did not have an order to monitor the AV fistula for thrill and bruit, and there was no consistent documentation of post-dialysis weights, mental status, pain, access site condition, and response to treatment. The facility's failure to implement its dialysis management policy and ensure proper communication and documentation led to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Address Pharmacy Consultant Recommendations and Maintain Documentation
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were maintained as part of the permanent medical record and did not address recommendations made by the pharmacy consultant in a timely manner for one resident. The facility's policy required the pharmacy consultant to report irregularities to the attending physician, medical director, and DON, and for the unit manager or designee to ensure all recommendations were acted upon. However, the medical record for a resident diagnosed with dementia and on antipsychotic therapy did not include the consultant pharmacist's recommendation from January 2024, despite multiple requests from the surveyor. The recommendation, which was eventually provided, indicated that an AIMS assessment was required every six months, but the last assessment had been completed 14 months prior. During an interview, the DON confirmed that the recommendation from the consultant pharmacist had not been reviewed or addressed by the facility, and that the required AIMS assessment had not been completed since January 2023. This failure to act on the pharmacy consultant's recommendations and to maintain proper documentation in the medical record led to the deficiency identified by the surveyors.
Failure to Properly Label and Secure Medications
Penalty
Summary
The facility failed to ensure staff properly labeled and stored all drugs and biologicals in accordance with currently accepted professional principles. Specifically, the facility did not label opened medications with the date they were opened and their new expiration dates. During a review of the Southwest Unit Medication 2 Cart, an opened bottle of Atropine sulfate ophthalmic solution and an opened bottle of Fluticasone propionate nasal spray were found without proper labeling. Nurse #9 confirmed that these medications should have been labeled with the date opened and the expiration date, acknowledging that using them past their shortened expirations could decrease their effectiveness. Additionally, the facility did not secure the North 1 medication storage room as required. The surveyor observed the medication storage room door wide open on two separate occasions without any staff present in the room or immediate area. This allowed free access to medications, including an emergency medication kit, nasal spray, and prescription migraine tablets. Unit Manager #1 confirmed that the medication storage rooms should be locked and secured at all times when staff are not present, as per the facility's policy.
Failure to Adhere to Resident's Documented Food Allergy
Penalty
Summary
The facility failed to provide a meal consistent with a resident's documented allergy to strawberries. Resident #26, who is cognitively intact and makes his/her own decisions, reported a consistent issue of receiving strawberry jam on his/her breakfast tray despite having a documented allergy. The resident's medical record, including the physician's orders, CNA visual/bedside kardex, medication and treatment administration records, and the comprehensive nutritional assessment, all indicated an allergy to strawberries. The resident's care plan also specified the need to maintain a diet free of strawberries. Despite these documented precautions, the resident continued to receive strawberry jam on his/her breakfast tray. The resident had previously discussed this issue with the food service director (FSD), who acknowledged the problem and attempted to resolve it. However, the issue persisted, as evidenced by an observation on 3/13/24 when the resident received a breakfast tray containing strawberry jam. The FSD expressed confusion about how the jam continued to appear on the tray, especially since the resident typically received a danish, not toast. Interviews with the resident and a CNA confirmed the ongoing issue, highlighting a failure in the facility's food service process to adhere to the resident's documented dietary restrictions.
Failure to Maintain Complete Hospice Documentation
Penalty
Summary
The facility failed to ensure services were coordinated with the hospice provider to implement the residents' plan of care as required in the provider contract agreement for two residents. For Resident #12, the facility did not maintain a complete medical record of services, including missing documentation such as the Election Form of Services, Consent to Treat, current Hospice Certification and Plan of Care, and documentation of visits after a certain date. Interviews with staff revealed a lack of clarity on how documentation was managed and filed, leading to incomplete records and missing orders for hospice services in the resident's chart. For Resident #70, the facility also failed to maintain a complete medical record of services. The hospice binder lacked current documentation, including the active Hospice Certification and Plan of Care and visit notes after a specific date. Interviews with staff indicated that the resident was still receiving hospice services, but the necessary documentation was not present in the binder. Staff were aware that the documentation should be in place but were unable to provide it during the survey. The facility's policy and hospice agreement required detailed and complete records for each hospice patient, including documentation of all services provided and events concerning the patient. However, the facility did not adhere to these requirements, resulting in incomplete and missing documentation for both residents. This failure hindered effective communication and continuity of care for the residents receiving hospice services.
Failure to Implement Vaccination Policies and Procedures
Penalty
Summary
The facility failed to implement policies and procedures to ensure residents or their representatives were educated on the benefits and potential side effects of immunizations, documented consent or refusal of the immunization, and offered and administered the influenza and pneumococcal immunizations in a timely manner. Specifically, for one resident, the facility did not provide education on the benefits and potential side effects, did not offer the immunizations, and did not document consent or refusal for the influenza and pneumococcal vaccines. The resident's medical record lacked documentation of receiving or refusing the vaccines, and the consent form was incomplete. The Infection Preventionist (IP) admitted to not tracking all vaccines or when residents are due for them. The IP also acknowledged that consents are obtained on admission, but there was no follow-up on the incomplete consent form for the resident in question. The IP further admitted to checking off boxes on the consent form without verifying the resident's vaccination status or providing the necessary Vaccine Information Statements (VIS). The IP did not speak directly to the resident regarding their vaccination status. Consulting staff confirmed that vaccines should be ordered and administered as soon as possible after consent is signed and that the IP is responsible for overseeing the vaccine program. The consulting staff also noted that the incomplete consent form should have been re-addressed with the resident and not filed in the medical record. There was no documentation in the resident's medical records regarding the two vaccines, indicating a failure in the facility's vaccination program oversight and documentation processes.
Failure to Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to implement policies and procedures to ensure that residents and their representatives were educated on the benefits and potential side effects of the COVID-19 vaccine, and to document consent or refusal of the immunization. Specifically, for one resident, the facility did not educate, offer, or administer the COVID-19 vaccine, nor did it document the consent or refusal in the medical record. The resident, who was cognitively intact and had a signed consent from their Health Care Proxy (HCP) dated six weeks prior, did not receive the vaccine, and there was no documentation indicating that the vaccine was offered or refused. The Infection Preventionist (IP) admitted to not tracking all vaccines or when residents were due for them. The IP also stated that consents were obtained on admission and that nurses were responsible for entering the orders. During a vaccine clinic, consents were mailed or emailed to HCPs, but the IP did not track who had not returned them. The IP was unaware that the consent for the COVID-19 vaccine was in the resident's chart and acknowledged that the vaccine should have been administered already. The Director of Nurses was unavailable for an interview, and another consulting staff confirmed that the vaccine should have been administered within a reasonable timeframe, which was not the case here.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident out of a sample of 24. Specifically, for Resident #108, the Brief Interview for Mental Status (BIMS) was not assessed, and the MDS incorrectly indicated the presence of an indwelling catheter. Resident #108 was admitted with diagnoses including urinary retention and chronic kidney disease. The MDS assessment dated 10/17/23 showed a BIMS score of 15, indicating cognitive intactness. However, the MDS assessment dated 1/10/2024 did not include a BIMS assessment and incorrectly noted an indwelling catheter, which was not supported by the physician's orders. During an interview, the MDS nurse confirmed the inaccuracies and stated that corrections were needed.
Lack of Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that training on the Quality Assurance and Performance Improvement (QAPI) program was included as mandatory training for all staff members. A review of staff education and competency records revealed that 11 sampled staff members, including nurses and certified nursing assistants (CNAs), did not receive mandatory training on the elements and goals of the QAPI program. During an interview, the Staff Development Coordinator admitted that she had not been providing staff with education on QAPI, and it was not part of the orientation or the yearly in-service training.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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