Cape Heritage Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandwich, Massachusetts.
- Location
- 37 Route 6a, Sandwich, Massachusetts 02563
- CMS Provider Number
- 225337
- Inspections on file
- 22
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cape Heritage Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Trash and refuse were observed overflowing from dumpsters and laundry carts, with bags and debris scattered on the ground and many receptacles left uncovered. Staff and the trash removal contractor reported that trash pickups were frequently missed due to non-payment, leading to ongoing unsanitary conditions. The administrator was unaware of the issue.
Essential kitchen equipment, including the walk-in freezer, stove hood, and ice machine, was not properly maintained. The freezer had a broken door seal, missing strip curtains, and significant ice buildup affecting food storage. The stove hood inspection was overdue, and the ice machine filter had not been changed as scheduled. Staff interviews confirmed lack of awareness and overdue maintenance for this equipment.
The facility did not maintain its septic system drain field or increase septic tank pumping, resulting in effluent water surfacing in the parking lot and creating a strong sewage odor. Staff and consultants confirmed the issue had persisted without resolution, and the facility was unable to provide a timeline or mitigation plan for the ongoing problem.
Surveyors found numerous unresolved maintenance and cleanliness issues on one unit, including broken fixtures, water damage, exposed wiring, and makeshift repairs. Multiple residents reported persistent problems such as broken beds, clogged sinks, and damaged furnishings, while staff interviews revealed inadequate reporting and tracking of maintenance needs. Facility leadership acknowledged the deficiencies and the need for better systems and staff awareness.
A resident with a chronic wound at a former G-tube site did not receive wound care as ordered, including failure to transcribe and implement updated stoma clinic recommendations, use the correct appliance size, and apply stoma powder daily. Documentation showed missed or unsigned treatments, and persistent skin maceration was not reported to the physician or clinic. Staff interviews revealed confusion about current orders and lack of communication with the resident's health care proxy.
Surveyors observed that the facility did not maintain proper food safety and sanitation in a kitchenette and the main kitchen. The kitchenette refrigerator and cabinets were found dirty, with food items mixed with trash and a leaking sink causing stains and soiling. In the main kitchen, multiple food items in the walk-in refrigerator and freezer were unlabeled, undated, improperly stored, or exposed to contamination, with open boxes and condensation present. The food service manager acknowledged that required labeling, dating, and storage practices were not followed.
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents expressed concerns about cold and bland food, and test tray evaluations confirmed that many food items were outside acceptable temperature ranges. The Food Service Director and Dietitian acknowledged these issues.
The facility failed to maintain sanitary conditions in the main kitchen, properly label and date food items, handle ready-to-eat food with proper hygiene, and clean and sanitize food-contact surfaces. Observations included buildup of debris, unlabeled food, improper glove use, and unclean prep tables. The FSD acknowledged these issues, which were not in line with the facility's policies.
The facility failed to maintain resident rooms in good repair, with several rooms having chipped and loose popcorn ceilings. Residents reported the disrepair had persisted for months, with concerns about safety and cleanliness. The Maintenance Director and Administrator were aware but had not yet completed repairs.
A resident reported a threat of harm from a visitor, but the facility failed to report the incident to the Department of Public Health's HCFRS within the required timeframe, despite notifying the police and obtaining a no trespass order.
The facility failed to secure psychotropic medication on a locked dementia unit, leaving a Trazodone tablet unattended on a medication cart, accessible to residents. Nurse #1 admitted the mistake, and both the Unit Manager and DON confirmed that prepared medication should not be left unattended.
A resident with dementia and diabetes experienced significant weight loss, and the facility failed to document the resident's weight as ordered by the physician. Despite orders to weigh the resident weekly, there were no documented weights between certain dates, and the Treatment Administration Record did not include numeric values for the weights.
The facility failed to ensure staff adhered to infection control protocols for PPE use during high-contact resident care activities, as required by the Enhanced Barrier Precautions Policy. Observations revealed staff inconsistently wore gowns and gloves and did not perform hand hygiene, despite posted CDC Enhanced Barrier Precaution signs.
The facility failed to ensure a clean and safe environment by not properly disposing of cigarette butts in designated smoking receptacles. Observations revealed numerous cigarette butts scattered around the smoking area, and staff interviews confirmed that residents were not allowed to smoke without supervision and that cigarette butts should be disposed of properly. The maintenance director admitted that while the cement area was swept daily, the grassy area was not often raked, leading to the accumulation of cigarette butts.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that trash, garbage, and refuse were properly disposed of and contained within receptacles constructed with tight-fitting lids, as required by the 2022 Food Code. Observations made by the surveyor revealed that both the recyclable cardboard and general refuse dumpsters were overflowing, with numerous trash bags, cardboard boxes, and miscellaneous debris scattered on the ground inside the fenced dumpster area. Additional trash, including black and clear plastic bags, was found overflowing from laundry carts and a dolly cart outside the fenced area, with several bags having fallen onto the ground. Many of these receptacles and carts were uncovered, further contributing to unsanitary conditions. Interviews with facility staff and the outside trash removal contractor indicated that the trash overflow was a frequent occurrence due to irregular trash pickups, which the contractor attributed to non-payment by the facility. Dietary staff confirmed that trash often overflows because it is not picked up regularly. The facility administrator stated she was unaware of the trash not being removed or of any payment issues. No information about residents' medical history or condition was provided in relation to this deficiency.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential mechanical equipment in the main kitchen in a safe and operable condition. Observations revealed that the walk-in freezer door could not fully seal due to ice buildup, with only two intact plastic freezer strip curtains and significant ice accumulation at the base of the door and inside the freezer. Frozen condensation was present on the ceiling, metal racks, and inside food boxes and packaging, including hamburger tubes encased in frozen condensation. The Director of Maintenance confirmed the freezer was frozen over when he started, the strip curtains were broken, and the door was not sealing. Additionally, the stove hood inspection was found to be overdue by 269 days, as indicated by the inspection sticker and confirmed by dietary staff. The ice machine filter was also overdue for replacement by three and a half months, with maintenance staff stating that a company is responsible for changing the filter and it had not been done. The Administrator was aware of the overdue hood inspection but not the freezer condensation or overdue ice machine service. The Food Service Manager was not aware of the regular maintenance schedule for the kitchen equipment, stating that maintenance handles all service and regular maintenance.
Failure to Maintain Septic System Results in Wastewater Surfacing
Penalty
Summary
The facility failed to maintain its septic system drain field in working order and did not increase the frequency of septic tank pumping to prevent liquid wastewater from running into the parking lot. Observations revealed water bubbling out from a manhole cover in the lower parking lot, creating a stream of water with a strong sewage odor. Interviews with consultants confirmed that the water was effluent that should have been leaching into the ground, but was instead surfacing due to the drain field not functioning properly. The last recorded septic tank pumping was in March, and no additional pumping had occurred since then, despite ongoing issues, especially during periods of heavy rain. Staff interviews indicated a lack of awareness and communication regarding the septic system's condition and maintenance schedule. The Maintenance Director had only recently started and was unaware of the full history, while the Regional Maintenance Director and Administrator could not provide a timeline of when the problem began or what mitigation steps had been taken. The facility did not provide the requested documentation or a mitigation plan during the survey, and the issue of wastewater surfacing in the parking lot remained unresolved at the time of the survey exit.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for residents on one unit, as evidenced by multiple maintenance and cleanliness issues observed during surveyor tours and confirmed by resident interviews. Specific deficiencies included loose and duct-taped keypads, missing bathroom light panels with exposed bulbs, broken heating panels, unpainted and water-damaged walls, peeling wallpaper, cracked and stained ceiling tiles, missing molding, frayed and ripped curtains, and missing or makeshift room number displays. Additional issues were found in common areas, such as an unlocked electrical panel with exposed wires, missing molding, water-damaged countertops, cabinets held together with zip ties, and a rotting exterior door with visible holes. Resident rooms also had problems such as dirty air conditioner filters, water damage, and damaged wheelchairs. Residents reported ongoing problems, including broken beds held together with duct tape, clogged sinks, and maintenance issues that had persisted since admission. Staff interviews revealed that maintenance relied on a notebook system for reporting issues, which was inconsistently used and primarily addressed staff-related concerns rather than resident needs. Both the Director and Regional Director of Maintenance acknowledged the poor condition of the unit and the inadequacy of the current reporting and tracking system. The Administrator confirmed expectations for a safe and homelike environment and recognized the need for improved processes and staff awareness regarding environmental standards.
Failure to Implement and Document Wound Care Orders for Resident with Gastrocutaneous Fistula
Penalty
Summary
A deficiency occurred when a resident with a chronic wound at a former gastrostomy tube site did not receive necessary wound care and services as ordered and recommended by consulting specialists. The facility failed to transcribe and implement updated wound care recommendations from the stoma clinic, including the use of a specific appliance size and frequency of stoma powder application. The orders in the medical record did not match the supplies being used, and the most recent recommendations for a smaller appliance size were not reflected in the physician's orders or in the supplies available to staff. Additionally, the daily application of stoma powder, as recommended after a hospital visit for maceration, was not transcribed into the electronic medication administration record (eMAR/eTAR), resulting in missed treatments. Documentation revealed multiple missed or unsigned wound care treatments, including appliance changes and application of silver nitrate and stoma powder. The transition from paper to electronic charting further contributed to incomplete transcription of orders, and there were several instances where the required treatments were not documented as completed. Progress notes indicated ongoing maceration of the skin around the wound, but there was no evidence that the physician or stoma clinic was notified of this persistent issue, as required by facility policy. Interviews with nursing staff and management confirmed a lack of clarity regarding the current treatment orders and the rationale for appliance selection. Staff were unsure why the orders and supplies did not match, and there was no documentation that the resident or their health care proxy was educated about or involved in decisions regarding changes to the wound care regimen. The Director of Nursing acknowledged that the orders and supplies should match, and that the physician and stoma clinic should have been notified of the ongoing maceration, but this did not occur.
Failure to Maintain Food Safety and Sanitation Standards in Kitchen and Kitchenette
Penalty
Summary
The facility failed to maintain food safety and sanitation standards in both a kitchenette and the main kitchen, as observed by surveyors. In one of the unit kitchenettes, the refrigerator contained a clear basket of creamers mixed with a used disposable wipe, artificial sweetener packets, alcohol prep pad cartons, and cartons of lactose-free milk. The door shelf held rolled-up used napkins, unlabeled peppermint patties, mayonnaise packets, and a carton of milk. A black insulated container was found on its side, unlabeled and stuck in a dried, sticky liquid on the shelf. The upper cabinets were visibly dirty with loose cup covers, random cups, and spoons. Under the sink, a leaking drainpipe had caused a large black stain on the cabinet floor, with a soiled white towel placed directly under the leak. In the main kitchen's walk-in refrigerator, multiple food items were found unlabeled, undated, or improperly stored. These included a large container of cooked macaroni, an unidentified food item wrapped in plastic, an unsealed package of partially cooked bacon, a metal container of cut watermelon, and several dishes of cut vegetables and salads. Some items were labeled with dates that exceeded the facility's policy for discarding potentially hazardous foods, while others were not labeled or dated at all. Raw chicken and hamburger were stored in reusable plastic bags without labels or dates and placed on top of other food items without drip trays, contrary to professional standards and facility policy. The walk-in freezer was also found to be in poor condition, with boxes stacked on the floor, heavy frozen condensation on the ceiling and boxes, thick ice buildup around the door, and open boxes with internal bags exposed to frozen condensation. Several food items, such as pancakes, biscuits, strawberries, pie crusts, and frozen patties, were not properly sealed. The food service manager confirmed that food should be labeled, dated, and discarded if older than three days, and that boxes and bags should be sealed to prevent condensation, but these practices were not followed.
Failure to Ensure Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents expressed concerns about the temperature and quality of the food, with complaints ranging from food being ice cold, bland, and visually unappealing. These concerns were consistently raised during Resident Council meetings and individual interviews with the survey team. Specific examples included residents stating that their food was often cold, with some resorting to ordering takeout or having family members bring them food due to the poor quality of the facility's meals. Test tray evaluations conducted by the survey team further confirmed these issues. During a lunch test tray, the food truck left the kitchen at 1:16 P.M. and arrived on the unit at 1:17 P.M., but the food temperatures recorded at 1:35 P.M. showed mixed vegetables at 124°F, a dinner roll at 127°F, and lasagna at 152°F. Similarly, a breakfast test tray showed an omelet and hashbrown at 123°F and orange juice at 56°F. The Food Service Director (FSD) acknowledged the issues but declined to taste the test trays. The Dietitian also noted that meal temperatures have been inconsistent, particularly for breakfast. Review of Room Test Tray Evaluation forms indicated that many food items were outside the acceptable temperature ranges. Examples included a pulled pork sandwich at 134.2°F, mixed vegetables at 122°F, and milk at 60.6°F upon delivery. These findings were consistent across multiple test trays conducted on different dates, with the Dietitian and Administrator both acknowledging the ongoing issues with food temperatures. The Administrator confirmed that he was aware of the residents' concerns and had experienced similar issues during his evaluations.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary condition, as observed by the surveyor. There was a buildup of food crumbs and debris along the perimeter of the kitchen floor, dried food splashes on large bins, dirty wheeled carts, cobwebs on shelving, and various items and debris on the floor in the dry storage room. The facility's policy required the kitchen to be kept clean and sanitary, but the most recent documentation of the Closing Check List was from several months prior, indicating a lack of regular cleaning and maintenance. The Food Service Director (FSD) acknowledged these issues during interviews, stating that the kitchen should be free of dust and debris to prevent contamination of food and surfaces. The facility also failed to properly label and date food items in the main kitchen refrigerators and dry storage areas. The surveyor found multiple opened food items without labels or dates, including ham luncheon meat, pre-cooked meatballs, cottage cheese, side salads, cubed potatoes, shredded cheese, muffin mix, and brown powder. The facility's policy required all food items to be labeled and dated, but this was not followed. The FSD and Regional FSD confirmed that all open food items should be labeled and dated, and acknowledged the discrepancies found by the surveyor. Additionally, the facility did not handle ready-to-eat food with proper hand hygiene and single-use gloves, leading to potential cross-contamination. The surveyor observed dietary staff making sandwiches without gloves, using soiled oven mitts, and handling food with the same gloves used for other tasks. The FSD admitted that oven mitts had not been laundered for months and that staff should change gloves and wash hands between tasks. Furthermore, the facility failed to clean and sanitize food-contact surfaces and utensils between uses. The surveyor observed staff placing sandwiches directly on a prep table and reusing a knife without cleaning or sanitizing them. The Regional FSD confirmed that these practices were not in line with the facility's policies and could lead to cross-contamination.
Facility Failed to Maintain Resident Rooms in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were maintained in good repair to promote a homelike environment on one of three units. Specifically, the facility did not repair areas of chipped and loose textured ceiling, also known as popcorn ceiling, in five resident rooms. During observations and interviews, several residents reported that the popcorn ceiling had been in disrepair for several months, with some areas peeling and falling. One resident mentioned that a piece of the ceiling fell and hit them on the head, although no injury occurred. The residents expressed concerns about the unsightly appearance and potential hazards of the peeling ceiling. The Maintenance Director acknowledged awareness of the issue and stated that efforts were being made to chip away loose areas and secure a vendor for repairs. The Administrator was also aware of the situation. Despite these acknowledgments, the ceiling remained in disrepair, affecting the residents' perception of their living environment and raising concerns about safety and cleanliness.
Failure to Report Alleged Abuse Incident in Required Timeframe
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident and a visitor within the required timeframe. Resident #66, who was admitted with diagnoses including dementia, diabetes mellitus, and PTSD, reported to the social worker that a visitor had threatened to harm them if they did not produce certain baseball cards. This incident was reported to the social worker on 3/24/24, but the facility did not submit a report to the Department of Public Health's Health Care Facility Reporting System (HCFRS) as required by their policy. Interviews with the Director of Social Services, Unit Manager, and Administrator confirmed that while the police were notified and a no trespass order was obtained to ensure the resident's safety, the incident was not reported in the HCFRS. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not. The failure to report the incident in the HCFRS constitutes a deficiency in adhering to the required reporting procedures.
Failure to Secure Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic medication was secured and not accessible to residents on the [NAME] unit, a locked dementia unit where 28 of 30 residents were diagnosed with Alzheimer's/dementia. Specifically, Nurse #1 was observed popping one Trazodone 12.5 mg tablet into a medication cup and placing it on top of the medication cart. Nurse #1 then walked down the hall to the nurses' station, leaving the medication cup unattended on the cart outside of room [ROOM NUMBER]. Four residents were observed standing around the medication cart, with one resident resting their hand on the cart. During interviews, Nurse #1 admitted to making a mistake by leaving the prepared medication unattended. Unit Manager #2 confirmed that prepared medication should never be left unattended. The Administrator and the Director of Nurses (DON) also stated that prepared medication should not be unattended and accessible to residents. The facility's policy indicated that medications should be stored in a locked mobile medication cart accessible only to licensed nursing personnel or in a locked medication room.
Failure to Document Resident Weight as Ordered
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident, specifically Resident #66, who had diagnoses of dementia and diabetes. The deficiency was identified when the facility did not document the resident's weight as ordered by the physician. The Minimum Data Set (MDS) assessment indicated that Resident #66 had experienced significant weight loss and was not on a prescribed weight loss regimen. A progress note dated 2/9/24 indicated that the resident's weights were trending down, and a new order was obtained to weigh the resident weekly for four weeks, then monthly. However, the weight summary showed no documented weights between 2/16/24 and 3/7/24, despite the Treatment Administration Record (TAR) indicating that the resident had been weighed on 2/24/24 and 3/2/24 without numeric values recorded. During interviews, the Unit Manager (UM) confirmed that the facility did not use a weight book and that weights were supposed to be recorded in the resident's TAR or electronic medical record. Upon review, it was found that the weights had not been documented as required. The Director of Nurses (DON) stated that the expectation was for weights to be obtained and documented in the resident's record as ordered, which was not done in this case.
Failure to Adhere to Infection Control Protocols for PPE Use
Penalty
Summary
The facility failed to maintain an infection prevention and control program, specifically in ensuring staff adhered to infection control protocols for personal protective equipment (PPE) use. Observations revealed that staff did not consistently wear gowns and gloves during high-contact resident care activities, as required by the facility's Enhanced Barrier Precautions Policy. For instance, a Certified Nursing Assistant (CNA) was observed sorting linen and changing a resident into a hospital gown with only one glove on and no additional PPE, despite a CDC Enhanced Barrier Precaution sign posted at the entrance of the room. Another instance involved two CNAs shifting a resident in bed while only wearing gloves and not performing hand hygiene upon exiting the room. Additionally, a CNA was seen feeding a resident and touching both the resident's face and her own face without gloves, and later improperly donning a gown and gloves after being informed of the required precautions. Interviews with staff, including the Infection Control Nurse (ICN) and the Director of Nurses (DON), confirmed that staff should follow the Enhanced Barrier Precautions signs posted outside of the rooms, which include wearing gowns and gloves during high-contact care activities and performing hand hygiene when entering and exiting the rooms. However, the observations indicated a lack of adherence to these protocols, leading to potential risks of transmission of communicable diseases and infections within the facility.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to ensure a functional, safe, and clean environment by not properly disposing of cigarette butts in designated smoking receptacles. Observations on multiple occasions revealed numerous cigarette butts scattered on the pavement and in the grass around the smoking area, despite the presence of a receptacle. Interviews with staff members confirmed that residents were not allowed to smoke without a staff member present and that all cigarette butts should be disposed of in the receptacle. However, the maintenance director admitted that while the cement area was swept every morning, the grassy area was not often raked, leading to the accumulation of cigarette butts. The facility's policy on smoking, revised in November 2020, aimed to provide a healthy and safe environment by limiting tobacco use and ensuring proper disposal of cigarette butts. Despite this policy, the surveyor's observations and staff interviews indicated non-compliance. The administrator acknowledged that the smoking area should be cleaned frequently and that cigarette butts should not be on the ground, but the maintenance director's comments highlighted a gap in the cleaning routine, particularly in the grassy area around the smoking zone.
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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