Cape Regency Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Massachusetts.
- Location
- 120 S Main Street, Centerville, Massachusetts 02632
- CMS Provider Number
- 225338
- Inspections on file
- 17
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cape Regency Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility did not ensure that essential kitchen equipment, including the plate warmer and walk-in freezer, was maintained in safe working order. The plate warmer was missing covers and functioned inconsistently, while the walk-in freezer had a damaged door seal, excessive condensation, and significant ice buildup on food and the floor. Staff and maintenance were aware of these ongoing issues, which had been reported verbally and documented, but repairs and replacements were not completed, leading to persistent unsafe conditions.
Two residents with wounds did not receive consistent care as required, including one who received two different treatments daily for the same arterial ulcer due to overlapping orders, and another whose weekly wound assessments and physician-recommended care were not properly documented or followed. Staff also failed to use appropriate dressings as ordered, leading to discomfort for a resident with fragile skin.
A resident with severe cognitive impairment was not assisted by staff in replacing missing bilateral hearing aids, resulting in repeated observations of the resident without hearing aids and unable to communicate effectively. Staff interviews revealed a lack of awareness and follow-through regarding the loss and replacement of the hearing aids, and no appointments were scheduled to address the issue.
A resident with osteomyelitis was receiving multiple medications, including opioids and a proton pump inhibitor, when consultant pharmacist recommendations to review and clarify the need for these medications were not addressed or were addressed late by the provider. Facility policy required timely communication and response to such recommendations, but documentation and interviews confirmed that these steps were not followed.
A resident with a recent hospital stay for knee surgery received nine extra doses of Eliquis due to duplicate orders entered in the eMAR. Nursing staff administered the medication as ordered without identifying the duplication, and required medication error reporting and investigation protocols were not followed after the error was discovered.
Surveyors identified multiple deficiencies in food safety and sanitation, including compromised kitchen floor coving and grout, rusted shelving in the walk-in refrigerator, and improper food storage in unit kitchenettes. Food items were found unlabeled, undated, or past expiration, and a kitchenette refrigerator had ongoing condensation issues with towels used to absorb leaks. Staff interviews confirmed these practices did not meet professional standards.
The facility did not maintain the garbage storage area in a sanitary condition, as a large pile of old wood pallets was observed stacked near the dumpster for an extended period. Multiple exterior bait stations showed ongoing pest activity according to pest control reports. Staff interviews confirmed the pallets had been present since the COVID period and there was no current plan for their removal.
The facility did not effectively use its resources to maintain the walk-in freezer, resulting in persistent condensation, ice buildup, and compromised door seals. Staff and maintenance were aware of the ongoing issues, which were documented in inspection reports and observed by surveyors, but repairs were delayed due to financial constraints and unpaid vendor invoices.
Multiple deficiencies were identified in the facility's infection prevention and control program, including incomplete infection surveillance documentation, failure to review and document lab results for residents tested for Group A Streptococcus, and lack of proper hand hygiene before meals. Staff did not consistently use PPE during high-contact care for residents on Enhanced Barrier or Contact Precautions, and failed to follow hand hygiene protocols during medication administration and dressing changes. Shared equipment was not properly disinfected between uses, and clean supplies were placed on unclean surfaces, reflecting widespread lapses in infection control practices.
Two residents were not treated with dignity and respect: one was not addressed by their preferred nickname despite family notification and visible signage, and another had their urinary catheter bag left uncovered and visible on multiple occasions, contrary to staff knowledge and facility policy.
A resident with severe cognitive impairment was admitted with a valid MOLST indicating DNR/DNI status, but the facility did not enact these orders and instead listed the resident as Full Code. The facility also lacked a policy for advance directive formulation.
A resident with a history of osteomyelitis and encephalopathy received nine extra doses of Eliquis due to a duplicate order entry. Staff failed to notify the physician and activated HCP of the medication error, and did not document the incident or complete a medication error report, contrary to facility policy.
Surveyors found that residents were not provided a homelike dining experience, as breakfast was served on trays at tables without tablecloths, contrary to staff expectations and practices at other meals. Additionally, a water-damaged wall with black speckles and ongoing moisture was observed around a built-in air conditioner, with maintenance staff unaware of the full extent of the issue.
Surveyors found that three residents had medications, including inhalers and nasal sprays, left unsecured in their rooms, despite facility policy requiring secure storage and proper assessment for self-administration. Staff interviews revealed confusion about storage requirements, and in some cases, residents had medications at the bedside without appropriate approval or secure storage, leading to a deficiency in medication management.
The facility did not follow its antibiotic stewardship protocols, as antibiotics were prescribed and continued for two residents whose symptoms did not meet infection criteria, and medical records lacked clear documentation of infection signs, symptoms, and prescriber rationale for continued antibiotic use.
Two residents were not properly screened for pneumococcal vaccine eligibility, and their medical records lacked documentation of education on vaccine benefits and side effects, as well as consent or declination forms. The DON confirmed the absence of required forms in both cases.
A resident with multiple medical conditions was found kneeling on the bathroom floor after an unwitnessed fall. The CNA reported the incident to the nurse, who assessed the resident but did not document the event or notify the physician or family, as required by facility policy. The deficiency was identified when the resident later reported pain and was diagnosed with a compression fracture.
A nurse failed to document, report, or communicate an unwitnessed fall after a resident was found on the bathroom floor. The nurse did not complete an incident report, notify the oncoming shift, or record an assessment in the medical record, despite facility policy requiring these actions. The resident, who had multiple medical conditions, later developed severe pain and was diagnosed with a compression fracture after delayed recognition of the incident.
The facility failed to maintain an accurate infection prevention and control program, ensure proper hand hygiene during medication administration and dressing changes, and implement correct transmission-based precautions for a resident suspected of having C. Diff. Incomplete surveillance reports and improper hand hygiene practices were observed, and incorrect signage for contact precautions was used.
The facility failed to document and address grievances and concerns from the Resident Council timely. Despite recurring issues such as call lights not being answered, staff not wearing name tags, and staff using cell phones in resident care areas, there was no written documentation or follow-up provided to the Resident Council. Interviews revealed that concerns were verbally communicated to department heads, but no resolutions were documented or reviewed with the Resident Council.
The facility failed to maintain a clean, comfortable, and homelike environment for residents. Observations included broken window screens, separating wall moldings, and multiple rooms with unpainted patches, scratches, dents, holes, and broken furniture. The Maintenance Director was aware of some issues but had not identified many of the problems, and resident areas were not included in the preventative maintenance tasks.
The facility failed to maintain safe and clean microwaves in three kitchenettes, with issues such as peeling paint, exposed metal, and a brown substance observed. Interviews revealed a breakdown in communication and responsibility among the Food Service Director, Director of Housekeeping, and Director of Maintenance.
The facility failed to implement an Antibiotic Stewardship Program effectively, resulting in incomplete antibiotic usage audit tools and unnecessary antibiotic prescriptions for residents. One resident with acute kidney failure and a questionable UTI received a full course of antibiotics despite urine culture results indicating no infection, and the resident's antibiotic usage was not documented in the monthly report tool.
The facility failed to maintain the kitchen walk-in freezer in safe operating condition, leading to significant frost and ice accumulation. The freezer door handle was broken, and the door did not close completely. Despite being aware of the issue for months, the facility had no current plans to fix the freezer.
The facility failed to develop baseline care plans within 48 hours of admission for two residents with a history of substance abuse. Despite being cognitively intact, the residents did not have care plans in place to manage their substance use disorders, as required by facility policy. Staff interviews confirmed the oversight was due to the absence of a stable substance use disorder counselor.
The facility failed to develop individualized, person-centered care plans for pain management for two residents, resulting in generic care plans that lacked non-pharmacological interventions and specific details about the residents' pain management needs. Staff interviews revealed a reliance on medication and a lack of awareness of non-medicinal pain relief methods.
A nurse failed to follow facility policy by leaving medication with a resident without observing its ingestion. The resident had not been authorized to self-administer medications, and the nurse admitted to this practice, which was confirmed as against the standard of care by the Regional Nurse.
The facility failed to store CPAP masks and tubing properly for two residents, leading to potential contamination. Observations showed the equipment exposed to environmental elements, and interviews confirmed the facility's expectation to use storage bags was not met.
A facility failed to maintain an effective pain management program for a resident with a stage four pressure ulcer, sepsis, and alcohol use disorder. The resident received inconsistent pain medication, including unnecessary narcotics, without clear guidelines or documentation of non-pharmacological interventions. Staff interviews revealed a lack of awareness and implementation of non-pharmacological pain management techniques.
The facility failed to provide consistent SUD counseling and services for two residents, leading to a deficiency. Both residents were initially assessed and agreed to weekly follow-up visits with a SAC, but only received one visit each, with no further follow-ups or care plans developed. The lack of follow-up and care plans was attributed to the SAC's leave of absence and the absence of a replacement counselor.
The facility failed to ensure medication carts were locked and secure when unattended on one out of three units observed. On multiple occasions, medication carts were found unlocked and unattended, with residents passing by them. Nurse #1 admitted to forgetting to lock the carts after assisting other staff.
The facility failed to obtain necessary lab tests for a resident with diabetes and a history of stroke, despite the physician's plan to check several lab parameters. The oversight was identified through medical record review and staff interviews.
The facility failed to update the nurse staffing plan accurately, resulting in insufficient staffing levels. The facility assessment indicated a 1:20 nurse-to-resident ratio for day and evening shifts, but actual staffing was one nurse to 30 residents. Interviews confirmed the discrepancy, and the ADON, DON, and Administrator acknowledged the assessment was incorrect.
Failure to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential mechanical equipment in the main kitchen in safe operating condition, specifically the plate warmer cart and the walk-in freezer. Observations revealed that the plate warmer lacked plate covers and functioned only sporadically, with one side not working and no covers or domes available for use. The Food Service Director (FSD) confirmed that the plate warmer had been unreliable for several months, and an additional unit provided from another facility was also nonfunctional. Staff and the Director of Maintenance (DOM) acknowledged ongoing issues with the plate warmer, which had not been fully addressed. The walk-in freezer exhibited multiple maintenance deficiencies, including a detached and cracked door seal, condensation and ice accumulation on the ceiling, floor, and food boxes, and a slippery floor inside the freezer. The FSD and DOM reported that these issues had persisted since before the last survey, with maintenance staff regularly chipping away ice as a temporary measure. The freezer door had not been repaired due to financial constraints, and the facility had not received or installed the necessary replacement parts. Maintenance logs indicated that staff were waiting for the door panel to be replaced while continuing to manage ice buildup on a weekly basis. Interviews with staff and review of inspection reports confirmed that the problems with the walk-in freezer and plate warmer had been communicated verbally and were known to both facility leadership and the local Board of Health. The facility's maintenance reporting system had shifted from a software platform to paper logbooks, with staff using various methods to report issues. Despite these reports, the underlying equipment deficiencies remained unresolved, resulting in continued unsafe conditions in the kitchen.
Failure to Provide Consistent Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that two residents with wounds received necessary treatment and services to promote healing, as required by their care plans and physician orders. For one resident with a history of cirrhosis who developed an arterial ulcer on the left foot, the medical record showed that after a wound infection was identified, the wound care consultant changed the treatment order to include Bactroban instead of Iodosorb. However, both the old and new treatments were administered daily on different shifts for several weeks, as the Iodosorb order was not discontinued when the Bactroban order was started. This resulted in two different treatments being performed on the same wound each day. Additionally, staff failed to follow the physician's order by applying an adhesive bandage to the arterial wound, which was not appropriate for the resident's fragile skin and caused discomfort during removal. For another resident admitted with osteomyelitis, right great toe amputation, and diabetes, the facility did not complete weekly skin assessments or follow the vascular physician's recommendations for care and treatment of a non-pressure wound on the right foot. The resident's physician orders lacked specificity regarding the treatment location, and the wound care recommendations from the consulting surgeon were not transcribed into the treatment orders. Documentation of wound measurements and descriptions was missing from the medical record, and weekly wound assessments were not consistently entered into the electronic health record. The wound nurse reported being unaware of the requirement to document wound information in the electronic health record and had not done so for several weeks. Observations and interviews confirmed that wound care practices did not align with facility policy, which required weekly assessments and thorough documentation for non-pressure wounds. The lack of clear, updated orders and incomplete documentation led to inconsistent wound care and failure to follow physician recommendations for both residents. These deficiencies were identified through record review, staff interviews, and direct observation by surveyors.
Failure to Replace Missing Hearing Aids for Resident with Severe Cognitive Impairment
Penalty
Summary
Staff failed to assist a resident with severe cognitive impairment in replacing missing bilateral hearing aids, resulting in the resident being observed multiple times without hearing aids and unable to engage in conversation due to hearing difficulties. The resident's clinical record indicated the presence of bilateral hearing aids and an audiology consult order, but there was no documentation of any appointment being scheduled to replace the missing devices. Interviews with staff revealed a lack of awareness regarding the loss and replacement of the hearing aids. The unit manager acknowledged the hearing aids had been missing for some time and that no action had been taken to replace them. Nursing and CNA staff were either unaware of the missing aids or did not know when they went missing, and the social worker stated it was only recently brought to her attention. The facility's appointment records did not show any effort to arrange for replacement hearing aids.
Failure to Timely Address Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) conducted by the consultant pharmacist were communicated to the physician and addressed in a timely manner for one resident. Specifically, a recommendation made in October 2024 by the pharmacy consultant to evaluate the continued need for Oxycontin and MS Contin was not reviewed or responded to by the provider, as indicated by the absence of documentation in the medical record and a blank physician response section. Additionally, recommendations made in February 2025 to reassess the need for Protonix and to review the use of as-needed Oxycodone were not acted upon until two months after the recommendations were received, as shown by the delayed physician signatures and orders. The resident involved had a history of osteomyelitis of the left tibia/fibula and was receiving multiple medications, including opioids and a proton pump inhibitor. The facility's policies required that all consultant pharmacist recommendations be communicated to and addressed by the provider within 30 days, with follow-up if no response was received. Interviews with the consultant pharmacist and the DON confirmed that the recommendations were either not addressed or were addressed late, contrary to facility policy.
Failure to Reconcile Medication Orders Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure accurate medication reconciliation for a resident following a hospital discharge, resulting in the administration of nine additional doses of Eliquis (apixaban) beyond what was ordered by the physician. The resident, who had a history of osteomyelitis and had recently undergone a left knee fusion, was prescribed Eliquis 2.5 mg twice daily for 30 days. Upon review, it was found that the medication order was entered twice into the electronic Medication Administration Record (eMAR), leading to duplicate administrations of the anticoagulant. The facility's policies required that medication reconciliation be performed at admission and after hospitalizations, with orders compared to hospital records and verified by a second nurse. However, these procedures were not followed, as the duplicate order was not identified during the initial review or subsequent daily clinical meetings. Multiple nurses administered the medication as documented in the eMAR, and none questioned the duplicate orders or documented any concerns. The error was only discovered after a surveyor brought it to the attention of the unit manager. Additionally, the facility's policy mandated immediate reporting and investigation of medication errors, including completion of a medication error report and notification of supervisory staff. In this case, although the unit manager and assistant director of nursing were made aware of the error, no medication error report was completed, and no formal investigation or documentation of the incident occurred. The director of nursing confirmed that the required protocol for medication error reporting and investigation was not followed.
Deficient Food Safety and Sanitation Practices in Kitchen and Unit Kitchenettes
Penalty
Summary
The facility failed to maintain food safety and sanitation standards in several key areas, as observed by surveyors. In the main kitchen, there were multiple areas where the floor coving and grout at the wall junctions were compromised, with deeply recessed grouting and damaged coving. The Food Service Director (FSD) acknowledged that these areas had previously harbored ants and required repair, and the Administrator confirmed that these areas were not in the expected condition. Additionally, the walk-in refrigerator in the main kitchen contained metal shelving with extensive rust, which both the FSD and Administrator agreed should not be present and needed replacement. In the unit kitchenettes, improper food storage practices were observed. Multiple food items in the refrigerators were found to be unlabeled, undated, or past their expiration or recommended use-by dates. Examples included containers of cottage cheese dated well beyond the three-day limit, opened containers of milk and other beverages without dates, and takeout or prepackaged foods lacking any labeling. The FSD confirmed that all food and drink items should be labeled and dated, and that items older than three days or past expiration should be discarded, which was not being done consistently. Further, the Unit 2 kitchenette refrigerator was found to have significant condensation issues, with thick condensation dripping onto food items and damp towels placed inside to absorb water. Staff reported that the refrigerator had been leaking for weeks, and towels were being changed daily to manage the water. The Director of Maintenance and Administrator indicated that the issue was caused by a resident overfilling the refrigerator, blocking airflow and causing cooling and defrosting problems, but were not aware of the ongoing condensation problem until the survey. These conditions contributed to an environment where food safety and sanitation were not adequately maintained.
Improper Disposal and Storage of Refuse Leading to Pest Activity
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition, as evidenced by the presence of a large pile of stacked wood pallets near the dumpster, which had accumulated up to the top of a wooden fence panel. Pest Control Service Inspection Reports over several months indicated ongoing activity in exterior bait stations, with varying numbers of stations showing pest activity on each inspection. During interviews, the interim Food Service Director and the Director of Maintenance both acknowledged the pallets had been present for an extended period, with the Director of Maintenance stating they had been there since COVID and could not be removed by the garbage disposal company due to their age. The Administrator confirmed awareness of the pallets and stated there was no current plan for their disposal.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that its resources were used effectively to maintain mechanical equipment in safe operating condition, specifically the walk-in freezer in the main kitchen. Multiple inspections and observations revealed ongoing issues with condensation and ice accumulation inside the freezer, including condensation on the door window, detached and cracked door seals, frozen condensation on the ceiling above food products, thick ice buildup on boxes and the floor, and a slippery walking surface. These issues were documented in town food inspection reports and observed by surveyors, with the problems persisting over an extended period. Interviews with facility staff, including the Food Service Director and Director of Maintenance, confirmed that the freezer's condition had been a longstanding concern, with staff resorting to manual removal of ice using hammers and shovels. Documentation showed that attempts to repair the freezer were hindered by financial issues, such as unpaid invoices to vendors and an unfulfilled order for a replacement door. Preventative maintenance logs indicated that maintenance staff regularly chipped away ice but were awaiting necessary repairs. The facility administrator acknowledged being new to the facility and was not aware of prior actions taken regarding the freezer.
Widespread Infection Control Failures and Documentation Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, documentation, and adherence to infection control protocols. The infection surveillance system was incomplete and inaccurate, with missing documentation of signs and symptoms for the majority of residents listed on monthly infection reports from January to April. The Infection Preventionist and nursing staff did not consistently document or review laboratory results, including those for Group A Streptococcus surveillance, where 71 residents were swabbed but results were not reviewed or documented in the medical record as required. Staff did not consistently perform or assist residents with hand hygiene prior to meals in the dining area, despite facility policy and staff interviews confirming this as an expectation. Observations revealed that staff served drinks and meals to residents without ensuring hand hygiene was performed. Additionally, staff failed to use appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions and Contact Precautions. For example, a CNA did not wear a gown or gloves while assisting a resident with a wound on Enhanced Barrier Precautions, and a nurse entered a contact precaution room, adjusted linens, and performed a dressing change without proper PPE or hand hygiene. Further deficiencies included improper hand hygiene and glove use during medication administration, such as injections and nasal sprays, and during dressing changes. Clean dressing supplies were placed directly on unclean surfaces without a barrier, and shared resident equipment, such as blood pressure cuffs, was not disinfected between uses. Staff interviews confirmed a lack of awareness or failure to follow established infection control policies, contributing to the observed lapses in infection prevention practices.
Failure to Uphold Resident Dignity and Preferences
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect in two specific cases. In the first case, a resident with a history of bipolar disorder and mental illness, who was cognitively intact, was not addressed by their preferred nickname despite the family informing staff of this preference. The resident's care plan and medical record did not reflect the preferred name, and staff continued to address the resident by their last name. Observations confirmed that even after signs were placed in the resident's room indicating the preferred nickname, staff persisted in using the last name during interactions. In the second case, a resident with significant urinary and kidney conditions, including retention of urine, hydronephrosis, and obstructive uropathy, had an indwelling catheter. On multiple occasions, the resident's urinary drainage bag was observed to be uncovered and fully visible, positioned on the bed rail facing the doorway, without a privacy bag. Several staff members, including CNAs and the unit manager, acknowledged that the catheter bag should have been covered to maintain the resident's privacy and dignity, but this was not done. Both deficiencies were identified through direct observation, interviews with staff and family, and review of medical records and care plans. The facility's own policies emphasized resident-centered care and the importance of recognizing individual preferences, but these were not followed in the cases described, resulting in a failure to treat the residents with the dignity and respect required.
Failure to Enact Resident's Advance Directives as Documented in MOLST
Penalty
Summary
The facility failed to ensure that a resident's advance directives were executed according to their documented wishes. Specifically, a resident with severe cognitive impairment was admitted with a valid Medical Orders for Life Sustaining Treatment (MOLST) form, signed by their Health Care Agent prior to admission, indicating Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Transfer to Hospital. However, the facility did not enact the MOLST and instead recorded the resident's code status as Full Code in the electronic medical record. Review of the paper record confirmed the presence of the valid MOLST, but there was no indication in the medical record that the facility had followed these orders. Additionally, the facility did not have a policy for the formulation of advance directives.
Failure to Notify Physician and HCP of Medication Error Involving Anticoagulant
Penalty
Summary
The facility failed to notify a resident's physician and activated Health Care Proxy (HCP) about a significant medication error involving the administration of nine additional doses of Eliquis (apixaban), an anticoagulant, due to a duplicate order entry. The resident, who was admitted with osteomyelitis and had a history of encephalopathy leading to HCP invocation, was prescribed Eliquis 2.5 mg twice daily for 30 days following a hospital discharge. However, the medication was entered into the electronic Medication Administration Record (eMAR) twice, resulting in the resident receiving double the intended doses over several days. The error was discovered when a surveyor identified the duplicate order and informed the Unit Manager (UM), who then discontinued one of the orders. Despite this discovery, there was no documentation in the medical record indicating that the resident's physician or HCP had been notified of the medication error. Additionally, the UM did not complete an incident report or conduct an investigation, only notifying the Assistant Director of Nursing (ADON) of the issue. Interviews with facility staff confirmed that the required notifications and documentation were not completed. The ADON acknowledged instructing the UM to notify the physician and discontinue the order but did not follow up to ensure this was done or complete a medication error report herself. The Director of Nursing (DON) also confirmed that there was no documentation of the error or required notifications in the resident's record, and that the facility's protocol for medication errors was not followed.
Failure to Maintain Homelike Dining Environment and Address Water Damage
Penalty
Summary
The facility failed to provide a homelike and comfortable environment for residents, as evidenced by observations in the third-floor dining room and a maintenance issue in a resident hallway. During multiple breakfast observations, residents were seated at a round folding table without a tablecloth, and all meals were served on trays rather than being placed directly on the tables. None of the tables had tablecloths during breakfast, which was inconsistent with lunch service where tablecloths were used and meals were served directly on the tables. Staff interviews confirmed that tablecloths should be used for all meals and that plates, bowls, and cups should be removed from trays, but staff reported that this was not their practice during breakfast. Additionally, there was no facility policy regarding the dining experience for residents. A separate deficiency was observed in the first-floor resident hallway, where a built-in wall unit air conditioner was surrounded by a water-damaged wall. The area between the windowsill and the air conditioner had black speckles and was wet to the touch, with bubbling paint and wet spackle nearby. Water was observed dripping from an upstairs air conditioner directly onto the unit below, causing the outside siding and the interior wall to be soaked. The Director of Maintenance was unaware of the extent of the water damage and the presence of black speckles until it was pointed out by the surveyor.
Failure to Securely Store Resident Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were labeled and stored in accordance with accepted professional standards for three residents. Specifically, medications such as inhalers and nasal sprays were observed left unsecured on bedside tables or in open areas of residents' rooms, rather than being stored in locked compartments as required. Facility policy allows bedside medication storage only for residents who have been assessed and approved for self-administration, with the stipulation that medications must be inaccessible to other residents. For one resident with COPD and shortness of breath, multiple inhalers and a nasal spray were found on top of the nightstand, despite orders permitting self-administration and bedside storage. However, staff interviews revealed uncertainty about whether these medications needed to be locked, and it was noted that at least one medication (Fluticasone Propionate Nasal Spray) should not have been at the bedside, as the resident was not approved to self-administer it. Another resident with a history of stroke and cognitive impairment had a nasal spray left unsecured in the room, even though the most recent assessment indicated no desire to self-administer medication. The physician's order for self-administration predated the assessment, and the record did not reflect the change in the resident's ability or desire to self-administer. A third resident with COPD was found with an inhaler left unsecured on the overbed table, which the resident stated was left by the night nurse and that they were not supposed to have. Staff interviews confirmed that these residents should not have had medications at the bedside unless proper assessments and secure storage were in place. The DON expressed uncertainty about the storage requirements for non-narcotic medications and indicated a need to review facility policy.
Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its own policies and procedures. The policies required the establishment of an antimicrobial stewardship team, use of McGeer's criteria to define infections, and specific documentation and reassessment protocols for antibiotic use. However, record reviews revealed that antibiotics were prescribed and continued for residents whose symptoms did not meet the facility's infection criteria, and there was a lack of clear documentation regarding the rationale for antibiotic use and continuation. For one resident with an upper respiratory infection concern, surveillance indicated that the case did not meet the criteria for infection, yet an antibiotic was prescribed for five days. The nursing progress notes initially lacked documentation of symptoms, and a late entry was made only after the antibiotic usage was questioned. Physician and nurse practitioner notes did not provide further specific signs or symptoms to justify continued antibiotic use, nor did they document the rationale for ongoing therapy despite not meeting McGeer criteria. Another resident was prescribed a seven-day course of antibiotics for a skin concern that also did not meet the infection criteria. Nursing notes mentioned swelling, but there was no further documentation of infection signs or symptoms, and physician and nurse practitioner notes did not address the infection or provide justification for antibiotic use. During an interview, the DON acknowledged that documentation should include all signs and symptoms of infection and the prescriber's rationale for antibiotic use, especially when criteria are not met, but this was not consistently present in the records reviewed.
Failure to Document Pneumococcal Vaccine Screening and Education
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility to receive the recommended pneumococcal vaccination, and that appropriate education and documentation were provided. For one resident, the medical record indicated a refusal of the pneumococcal vaccine, but there was no documentation that the resident's vaccination history had been obtained, eligibility determined, or that education regarding the benefits and potential side effects of the vaccine was provided. Additionally, there was no evidence of a consent or declination form being obtained. For the second resident, the medical record did not indicate whether the resident had received or refused the pneumococcal vaccine, nor did it show that vaccination history was obtained or eligibility determined. There was also no documentation of education provided to the resident or their legal representative, and no consent or declination form was found. The Director of Nurses confirmed that the required forms were missing from both residents' medical records.
Failure to Notify Physician and Family After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident experienced an unwitnessed fall during the night shift and the facility failed to notify the resident's physician and family member as required by facility policy. The resident, who had a history of a displaced comminuted fracture of the humerus, difficulty walking, anxiety disorder, chronic kidney disease, hypertension, COPD, and hyperlipidemia, was found kneeling on the bathroom floor by a CNA after being alerted by the resident's roommate. The CNA assisted the resident back to bed and reported the incident to the nurse on duty, stating that the resident claimed to have slipped on water and was not in pain. The nurse on duty assessed the resident, found no apparent distress or pain, and did not consider the incident a fall because she had not witnessed it. As a result, she did not complete an incident report, document the event or her assessment in the medical record, or notify the physician or family member. This was in direct violation of the facility's policies, which require notification and documentation whenever a resident is found on the floor, regardless of whether the fall was witnessed or if the resident reports pain. The lack of documentation and notification was later discovered when another nurse completed an incident report after the resident reported the fall and subsequent pain. The resident was later sent to the hospital and diagnosed with a T11 compression fracture. Interviews with staff and review of records confirmed that the required notifications and documentation were not completed at the time of the incident.
Failure to Document and Report Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards and facility policy after a resident was found on the bathroom floor during the night shift. Although the certified nurse aide (CNA) reported the incident to the nurse, the nurse did not document the assessment, did not complete an incident report, and did not notify the oncoming shift nurse, physician, or the resident's family. The nurse also did not record any findings or actions in the resident's medical record, despite acknowledging that any time a resident is found on the floor, it is considered a fall according to facility policy. The resident involved had multiple medical diagnoses, including a recent humerus fracture, difficulty walking, anxiety disorder, chronic kidney disease, hypertension, chronic obstructive pulmonary disease, and hyperlipidemia. After being found on the floor, the resident initially reported no pain and declined having fallen, stating instead that they had slipped due to water on the floor. The CNA assisted the resident back to bed and informed the nurse, who performed a brief assessment but did not document it or initiate required post-fall protocols. Subsequent shifts were not informed of the incident, and the lack of documentation and communication led to a delay in recognizing the resident's injury. The following day, the resident complained of back pain and was eventually sent to the hospital, where imaging revealed a compression fracture in the thoracic spine. The facility's policies required documentation, incident reporting, and monitoring after any unwitnessed fall, none of which were completed by the nurse on duty at the time of the incident.
Infection Control and Prevention Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, which included a complete and accurate system of surveillance to identify any trends or potential infections. The facility's policy required the Infection Preventionist (IP) to perform surveillance and investigation of infections, but the Monthly Resident Infection and Antibiotic Stewardship Report tools for December 2023, January 2024, and February 2024 were incomplete. The Staff Development Coordinator (SDC) and the IP admitted that the surveillance was only conducted for residents taking antibiotics and not for other potential illnesses, leading to missing documentation for numerous residents. The Director of Nursing (DON) confirmed that the infection surveillance was incomplete and did not meet the facility's expectations. The facility also failed to ensure staff performed proper hand hygiene during medication administration and dressing changes. During a medication pass, a nurse was observed not performing hand hygiene before and after preparing medications for multiple residents and touching medications with bare hands. The nurse acknowledged the error and the Regional Nurse confirmed that the nurse did not meet the facility's policy and standard of practice. Additionally, during a dressing change for a resident with a sacral wound, a nurse did not perform hand hygiene between glove changes, which was against the facility's policy. The nurse admitted the mistake, and the Regional Nurse reiterated the importance of hand hygiene between glove changes. Furthermore, the facility did not implement transmission-based precautions (TBP) according to CDC guidance for a resident suspected of having Clostridium Difficile (C. Diff). The resident had a physician's order for contact precautions, but the signage outside the resident's room indicated enhanced barrier precautions instead. An activity assistant entered the resident's room without performing hand hygiene, and the Unit Manager and Staff Development Coordinator later confirmed that the incorrect signage was used. The Regional Nurse stated that contact precautions should have been in place to prevent the transmission of C. Diff.
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, including the facility response and rationale for review with the Resident Council. During a group meeting with 15 residents, it was revealed that similar concerns were brought forward monthly, but the residents were unsure of what happened to these concerns and received little follow-up. The Resident Council Meeting Minutes from the past three months indicated unresolved concerns such as call lights not being answered promptly, staff not wearing name tags, staff using cell phones in resident care areas, and staff speaking in different languages. However, there was no documentation of resolutions to these concerns being reviewed and discussed with the group, nor were there any group grievance or resolution forms related to the ongoing concerns brought forward by the group. Interviews with the Social Worker, Recreation Director, and Administrator revealed that while concerns were verbally communicated to department heads, there was no written documentation or follow-up provided to the Resident Council. The Social Worker mentioned that she documents concerns in the grievance log, but a review of the log failed to indicate any grievances/concerns brought forward by the Resident Council for the previous three months. The Recreation Director admitted to not documenting the concerns in writing and not reviewing resolution plans with the Resident Council. The Administrator expected department heads to follow up with resolutions but did not ensure that these resolutions were communicated back to the Resident Council. This lack of documentation and follow-up led to the deficiency identified by the surveyors.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility did not maintain the residents' rooms and environment in good repair on one of three resident care units. Observations included broken window screens, wall molding separating from the walls, and multiple resident rooms with various forms of disrepair such as unpainted patches, scratches, dents, holes, and broken furniture. These issues were observed over several days and were not addressed despite being evident for an extended period, as noted by a family member who mentioned the room had been in disrepair for about six months. During interviews, it was revealed that the Maintenance Director was aware of some issues but had not identified many of the problems observed by the surveyor. The Maintenance Director admitted that resident areas and rooms were not included in the preventative maintenance tasks and frequencies list. This lack of attention to the residents' living environment led to the observed deficiencies, indicating a failure in the facility's maintenance program to ensure a safe, clean, and homelike environment for the residents.
Failure to Maintain Safe and Clean Microwaves
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation, specifically in maintaining safe and clean microwaves in three out of three kitchenettes. The surveyor observed that the microwaves on the first, second, and third floors had significant issues such as peeling paint, exposed metal, and a brown substance on the inside of the microwave door. These conditions could potentially lead to the spread of foodborne illness among residents who are at high risk. Interviews with the Food Service Director, Director of Housekeeping, and Director of Maintenance revealed a breakdown in communication and responsibility. The Food Service Director acknowledged that the microwaves should not be in use due to their condition and that housekeeping staff should have reported the issue. The Director of Housekeeping stated that her staff had notified her about the concerns, and she had reported them to a maintenance assistant. However, the Director of Maintenance was unaware of the issues, and no new microwaves had been ordered.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program effectively, as evidenced by incomplete antibiotic usage audit tools and the unnecessary prescription of antibiotics for residents. The facility's policy on Antibiotic Stewardship, revised in October 2022, mandates the establishment of an antimicrobial stewardship team and the use of audit tools to track and evaluate antibiotic prescribing patterns. However, the Monthly Resident Infection and Antibiotic Stewardship Report tools for December 2023, January 2024, and February 2024 were found to be incomplete, with missing documentation on signs and symptoms of illness for numerous residents who were prescribed antibiotics. Specifically, 23 out of 25 residents in December, 16 out of 16 residents in January, and 11 out of 13 residents in February had no documented signs or symptoms of an illness, yet all were prescribed antibiotics. Resident #40, admitted in January 2024 with acute kidney failure and a urinary tract infection (UTI), was prescribed Ciprofloxacin for a questionable UTI. The urine culture results indicated contamination or colonization, suggesting no actual infection. Despite this, Resident #40 received the full course of antibiotics, and the February 2024 Monthly Resident Infection and Antibiotic Stewardship Report tool failed to include any information regarding this resident's UTI, antibiotic usage, or signs and symptoms of infection. The Infection Preventionist (IP) admitted that Resident #40 did not meet the McGeer Criteria for antibiotic use and that the physician should have been notified and the notification documented. Interviews with the Staff Development Coordinator (SDC), the IP, and the Director of Nursing (DON) revealed gaps in the facility's antibiotic tracking and reporting processes. The SDC, who was assisting the IP, acknowledged the incomplete report tools and the lack of surveillance for other potential illnesses. The IP, who was covering for the primary IP on leave, was unaware of how to complete the monthly infection reports and admitted to not following up with physicians within three days of antibiotic use. The DON confirmed that the antibiotic tracking books were monitored by the IP and that Resident #40 should have been included in the February 2024 report tool, with the physician notified of the continued antibiotic use, which did not happen.
Failure to Maintain Kitchen Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure the kitchen walk-in freezer was maintained in safe operating condition. On multiple occasions, the surveyor observed significant frost accumulation on the outside window of the freezer door, ice on the floor inside the freezer, and ice on food items and equipment within the freezer. The freezer door handle was broken, and the door did not close completely, leading to these issues. The Food Service Director confirmed that the handle had been broken for months, and despite daily efforts to chip away the ice, the problem persisted. The Administrator and Director of Maintenance were aware of the issue, but no current plans were in place to fix the freezer. The Food Service Director mentioned that a repair company had evaluated the freezer months prior, but the problem remained unresolved. The kitchen staff had to discard freezer-burned food frequently due to the malfunctioning freezer. The Director of Maintenance acknowledged that the gasket had been replaced previously, but no estimate had been obtained for fixing the broken handle. The Administrator was aware of the situation but deferred to the Director of Maintenance for the plan, which was non-existent at the time of the survey.
Failure to Develop Baseline Care Plans for Residents with Substance Abuse History
Penalty
Summary
The facility failed to ensure that baseline care plans were developed for two residents with a history of substance abuse within 48 hours of their admission. Resident #257, admitted with a diagnosis of alcohol abuse, and Resident #259, admitted with a history of cocaine abuse, did not have baseline care plans in place to assist in managing their substance use disorders. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission, this was not done for either resident. Interviews with facility staff, including a social worker, consulting staff, and the Director of Nurses, confirmed that the baseline care plans were missed due to the absence of a stable substance use disorder counselor. The social worker acknowledged that care plans should have been in place at the time of admission, and the Director of Nurses confirmed that the deficiency was only identified when brought to their attention by the surveyor. This oversight resulted in the lack of immediate care planning for the residents' substance use disorders upon their admission to the facility.
Failure to Develop Individualized Pain Management Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered care plans for pain management for two residents, leading to deficiencies in their care. Resident #257, admitted with diagnoses including a stage four pressure ulcer and sepsis, was found to have a generic pain management care plan that did not include non-pharmacological interventions or specific details about the resident's pain management needs. Despite the resident's ability to vocalize pain and a clear indication of pain triggers and relief methods, the care plan lacked specificity and did not reflect the resident's personal pain goal or the use of non-medicinal interventions. Staff interviews revealed a lack of awareness and implementation of non-pharmacological pain relief methods, further highlighting the inadequacy of the care plan. Similarly, Resident #259, admitted with diagnoses including sepsis, discitis, and chronic back pain, had a pain management care plan that was also generic and not tailored to the resident's specific needs. The pain evaluation for this resident was incomplete, missing critical information such as the location, duration, and quality of pain, as well as triggers and relief methods. The care plan did not reflect the resident's personal pain goal or the involvement of skilled rehab and a pain clinic referral. Staff interviews indicated a reliance on medication for pain management without consideration of non-medicinal interventions, underscoring the lack of individualized care. The Director of Nursing and Unit Manager acknowledged that the care plans for both residents were not specific to their individual needs and goals. They admitted that the care plans were generic and did not meet the resident-centered goals as outlined in the facility's policy. The failure to develop and implement comprehensive, individualized care plans for pain management resulted in inadequate care for the residents, as evidenced by the lack of non-pharmacological interventions and the absence of detailed, resident-specific information in the care plans.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards and facility policy for one resident. Specifically, a nurse poured liquid protein into a cup for a resident and left the cup with the resident without observing the resident ingest the medication. This action was against the facility's policy, which requires the nurse to stay with the resident until the medication is swallowed. The resident had signed a form indicating they wished to have their medications administered by the nurse, and there was no physician's order authorizing the resident to self-administer medications. During interviews, the nurse admitted to typically leaving medications with residents who she assumed were capable of taking them on their own, acknowledging that this practice was against the standard of care. The Regional Nurse confirmed that the nurse should not have left the medication at the resident's bedside and should have ensured the medication was taken as ordered. The facility's policy and the standard of practice were not followed in this instance, leading to the deficiency.
Improper Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure the proper storage of CPAP masks and tubing for two residents, leading to potential contamination. Resident #33, who was admitted with acute and chronic respiratory failure and chronic obstructive pulmonary disease, was observed multiple times with their CPAP mask and tubing stored in an unsanitary manner inside an open top drawer of the bedside table. The equipment was exposed to environmental elements, increasing the risk of contamination. Despite the facility's protocol to provide storage bags for such equipment, Resident #33 did not have a storage bag available in their room, as confirmed by Nurse #5 and the Assistant Director of Nursing (ADON). Similarly, Resident #65, admitted with chronic pulmonary embolism and sleep apnea, was observed with their CPAP mask and tubing left exposed on the bedside table, not stored in a sanitary manner. The resident was unaware of the facility's expectations for storing the equipment and had not been provided with a storage bag. Observations over several days showed the equipment consistently exposed to potential germs and environmental debris. Interviews with the ADON, Unit Manager #2, and the Regional Nurse confirmed that the facility's expectation was to store all respiratory equipment in labeled respiratory storage bags when not in use, which was not adhered to in this case. The failure to store CPAP masks and tubing properly for both residents was a breach of infection control standards. The facility's staff, including the ADON and Regional Nurse, acknowledged that the expectation to use storage bags was not met, leading to the potential contamination of the respiratory equipment. This deficiency highlights a lapse in following professional standards of practice for respiratory care within the facility.
Inconsistent Pain Management for Resident
Penalty
Summary
The facility failed to maintain an effective resident-centered pain management program for a resident with a stage four pressure ulcer, sepsis, and alcohol use disorder. The resident reported constant pain, typically around a 5 on a 0-10 scale, which worsened with therapy or wound treatment. Despite the resident's pain management goal being a 5, the facility's staff inconsistently administered pain medications without clear guidelines on which medication to use based on the resident's pain level. The resident was frequently given Oxycodone, even for pain levels as low as 0, without documentation of non-pharmacological interventions or reasons for administering narcotics at such low pain levels. The facility's policy required the use of both pharmacological and non-pharmacological interventions, but the staff failed to offer or document any non-pharmacological pain management techniques for the resident. Interviews with nurses and CNAs revealed a lack of awareness and implementation of non-pharmacological interventions, and the care plan did not specify which non-pharmacological methods should be attempted. The facility's failure to provide clear guidelines and consistent documentation led to the resident receiving inconsistent pain management, including unnecessary administration of narcotic pain medication.
Failure to Provide Consistent Substance Use Disorder Counseling and Services
Penalty
Summary
The facility failed to consistently provide substance use disorder (SUD) counseling and services for two residents, leading to a deficiency. Resident #257, admitted with diagnoses including alcohol use disorder, was initially assessed and agreed to weekly follow-up visits with a substance abuse counselor (SAC). However, the resident only received one visit, and no subsequent follow-ups were documented. Additionally, there was no care plan developed to assist the resident in managing their substance abuse or the treatment and support the SAC was to provide. The social worker and unit manager confirmed the lack of follow-up and care plan, attributing it to the SAC's leave of absence and the absence of a replacement counselor to maintain the schedule and care plan development. Similarly, Resident #259, admitted with diagnoses including cocaine abuse, major depressive disorder, and generalized anxiety disorder, was also assessed and agreed to weekly follow-up visits with the SAC. Like Resident #257, Resident #259 only received one visit, and no further follow-ups were documented. There was also no care plan developed to assist the resident in managing their substance abuse. The social worker and unit manager acknowledged the missed visits and lack of care plan, citing the same reasons as for Resident #257. Interviews with the residents revealed their disappointment and confusion over the lack of follow-up visits and support. Both residents expressed a desire to continue receiving SUD services and support. The facility's administrator and regional nurse admitted that the SUD program was not fully implemented due to the SAC's unavailability, leading to missed visits and the absence of care plans. The director of nurses confirmed that the vital pieces of the SUD program were not in place as they should have been for the residents involved.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure the secure storage of medications on one out of three units observed. Specifically, the medication carts were found unlocked and unattended on multiple occasions. On 03/26/24 at 9:05 A.M., a medication cart on the first floor south side was observed unlocked and unattended in the hallway outside of a resident's room. A resident in a wheelchair and another ambulating resident were seen passing by the unsecured cart. Nurse #1 later locked the cart and admitted it should have been locked when unattended but had forgotten to do so after assisting another nurse. Later the same day at 2:18 P.M., another medication cart was observed unlocked and unattended at the nursing station on the first floor. A resident was seen ambulating past this unsecured cart as well. Nurse #1 again locked the cart upon returning and acknowledged that it should have been locked when left unattended. The facility's policy requires that medication carts be locked when not in use and accessible only to licensed nursing personnel, which was not adhered to in these instances.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure laboratory services were obtained for a resident with diagnoses of diabetes and a history of a stroke with left-sided hemi-paresis. The resident was seen by the physician for generalized weakness and a slow progressive decline, and the physician's plan included checking several lab tests, including CBC, CMP, HgbA1c, lipid panel, and TSH. However, the medical record review indicated that these labs were not completed as ordered by the physician. Interviews with Nurse #4 and the Assistant Director of Nurses revealed that the labs should have been ordered when the physician's progress note was received and that the nurse who received the physician's interim order should have entered the CBC and CMP in the electronic lab system. The failure to order and complete the necessary lab tests as per the physician's plan led to the deficiency identified in the report.
Failure to Update Nurse Staffing Plan
Penalty
Summary
The facility failed to accurately update the nurse staffing plan to reflect the current needs of the facility upon completion of their annual assessment. The Facility Assessment, last revised on 1/12/2024, indicated a staffing ratio of 1:20 for licensed nurses during day and evening shifts and 1:40 during night shifts. However, the daily nurse staffing logs from 3/26/24 through 4/1/24 showed that only one nurse was scheduled to work alone on the first and third floors during day and evening shifts, despite these units having more than 20 residents each. Interviews with the Nurse Scheduler, Unit Manager, and nurses confirmed that the actual staffing ratio was one nurse to 30 residents, not the 1:20 ratio stated in the facility assessment. The ADON and DON acknowledged that the facility assessment was incorrect and had not been updated properly during the annual review. The Administrator also confirmed that the facility assessment was not updated accurately and that the current nurse staffing ratio should reflect one nurse to 30 residents for day and evening shifts. The failure to update the nurse staffing plan accurately led to insufficient staffing levels, which could impact the quality of care provided to residents.
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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