Care One At Brookline
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookline, Massachusetts.
- Location
- 99 Park Street, Brookline, Massachusetts 02146
- CMS Provider Number
- 225509
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Care One At Brookline during CMS and state inspections, most recent first.
The facility failed to address ongoing concerns raised by the Resident Council regarding the lack of condiments and adherence to menu choices. Despite repeated documentation of these issues in Resident Council Minutes and interviews with residents and staff, the facility did not take sufficient action to resolve the problems, leading to a diminished dining experience for residents.
The facility failed to secure resident PHI on medication carts, as computer screens displaying sensitive information were left open and unattended on two nursing units. Staff interviews confirmed that such screens should not be left open without a nurse present.
The facility failed to implement physician orders and document care for several residents, including not applying prescribed waffle boots for a resident at high risk for pressure ulcers, not obtaining and documenting weights for residents with chronic conditions, and not initiating orders for IV and central line care. These deficiencies highlight significant lapses in adhering to professional standards of practice.
The facility experienced a medication error rate of 23.33%, exceeding the acceptable limit of 5%. Three nurses made errors affecting three residents, including incorrect dosages and missed medications. The Director of Nursing acknowledged the issue, noting that medications should be administered as ordered.
The facility failed to secure medications properly, leaving them unattended on medication carts, at nurses' stations, and in resident rooms. A medication cart was found unlocked on the 3rd floor, and lidocaine patches were left at a resident's bedside. Medications were not labeled with the date opened, and a resident had unauthorized access to Motrin B. These actions were contrary to the facility's policies and procedures.
The facility failed to accurately document care for several residents, including diabetic foot care, oxygen tubing changes, and the use of a hand splint. Additionally, medication administration was not properly documented for a resident with cerebral infarction and vascular dementia. These documentation lapses were confirmed by the Director of Nursing.
A resident with PTSD, anxiety, and depression was found with a bottle of Motrin B at their bedside without an assessment for self-administration. The medical record lacked documentation of an assessment, doctor's order, or care plan for self-administration. A nurse confirmed the resident should not have medications at bedside.
A facility failed to create a baseline care plan within 48 hours for a resident admitted with osteomyelitis, a spinal abscess, and on IV antibiotics. The medical record review showed no plan was developed even five days post-admission. The DON confirmed that the nursing staff should have developed the plan within the required timeframe.
A resident with a history of stroke, diabetes, and depression was not provided with a hand brace or nail trimming as required by their care plan. The resident's hand brace was missing for a month, and staff failed to assist with nail care. Interviews revealed a lack of communication and awareness among staff regarding the resident's needs, with confusion over responsibilities for applying braces and trimming nails.
The facility did not ensure a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team as required. The care plan had not been updated since July, despite an MDS being completed in October. The resident had diagnoses including schizophrenia, anxiety disorder, and depression. The DON confirmed that care plans should be reviewed with each MDS completion.
The facility failed to assist three residents with personal hygiene needs, including cutting fingernails and removing unwanted chin hair, despite their dependence on staff for activities of daily living. One resident with schizophrenia and moderate cognitive impairment was observed with long nails and chin hair, while another resident with stroke and diabetes had long nails, and a third resident with cancer had significant chin hair. The residents expressed embarrassment and a lack of assistance, highlighting a deficiency in the facility's care provision.
A resident with severe cognitive impairment and aphasia was not provided with meaningful activities as per their care plan. Despite being bedbound and nonverbal, the resident was observed multiple times without engagement in activities, and the Activities Director was unaware of this oversight. The resident's Activity Participation Record showed no in-room activities on several dates, indicating a failure to adhere to the care plan.
A resident with chronic conditions was found with outdated oxygen tubing and a dirty concentrator filter, contrary to doctor's orders and professional standards. The facility's policy lacked specific guidelines for equipment maintenance, and the DON could not provide manufacturer's cleaning instructions.
A resident with multiple health conditions did not receive appropriate pain management due to the incorrect application of lidocaine patches. The facility staff applied 5% patches instead of the prescribed 4% patches and placed them on incorrect body sites, contrary to the physician's orders. Interviews with nursing staff confirmed the error, and the DON acknowledged the need for correct verification of patch strength and application site.
A facility failed to develop a trauma-informed care plan for a resident with PTSD within the required timeframe. Despite the facility's policy requiring individualized care plans to address past trauma, no baseline care plan was created within 48 hours of the resident's admission. Interviews with the DON and Regional Social Service Director confirmed the oversight.
A facility failed to review and implement a consultant pharmacist's recommendations for a resident's medication regimen reviews. The resident, with conditions including diabetes and heart failure, had recommendations to discontinue certain medications due to nonuse and evaluate another's necessity. Despite policy requirements, the Director of Nursing did not receive the recommendations, and they were not addressed by nursing staff or the physician.
A nurse failed to follow infection control practices by handling medications with bare hands during a medication pass, potentially contaminating the medications and bottles. Both the nurse and the DON acknowledged the breach of protocol.
Failure to Address Resident Council Concerns on Food Service
Penalty
Summary
The facility failed to ensure adequate follow-up on concerns raised by the Resident Council Group, particularly regarding the availability of condiments and adherence to menu choices. During a tour of the facility's kitchenettes, it was observed that condiments such as creamers, butter, salt, and pepper were missing. A resident expressed frustration over the inability to obtain condiments when requested, with staff citing a lack of supply. This issue was corroborated during a Resident Group interview, where residents reported that menus were not followed, and condiments were often missing from meal trays, leading to a diminished dining experience. The Resident Council Minutes from August, September, and October consistently documented concerns about the lack of condiments and non-compliance with menu choices. Despite these recurring issues, the facility did not take sufficient action to address and prevent the recurrence of these problems. Interviews with various staff members, including the Ombudsman, Dietitian, Food Service Director, and Administrators, revealed awareness of the ongoing issues but no effective resolution. The facility's policies on Resident Council and Grievances/Complaints outline procedures for addressing resident concerns, but these were not adequately implemented. The Grievance Officer is responsible for investigating complaints and ensuring corrective actions, yet the residents' grievances about food service were not resolved. The lack of condiments and adherence to menu choices remained unaddressed, indicating a failure in the facility's response to resident feedback.
Failure to Secure Resident PHI on Medication Carts
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on two of its three nursing units. Observations by the surveyor revealed that computer screens on medication carts were left open and unattended, displaying residents' names, photos, and identifying information. This occurred on multiple occasions across different floors, with no nurse present to monitor the information being displayed. Interviews with facility staff, including a Unit Manager and the Director of Nursing (DON), confirmed that the medication administration computer screens should not be left open unless a nurse is present. The Unit Manager acknowledged the issue when observed by the surveyor, and the DON reiterated that resident information should only be visible to the nurse attending the medication cart. These lapses in protocol led to the exposure of sensitive resident information, violating the facility's policy on confidentiality and personal privacy.
Deficiencies in Implementing Physician Orders and Documentation
Penalty
Summary
The facility failed to meet professional standards of practice for five residents, leading to deficiencies in care. For one resident, the facility did not implement a physician's order to offload heels and apply waffle boots, despite the resident being at very high risk for developing pressure ulcers. Observations over two days showed the resident lying in bed with feet flat on the bed and without the prescribed waffle boots. The unit manager confirmed the resident's heels were not offloaded, and the boots were not applied as ordered. Another resident, who was cognitively intact and at risk for weight fluctuations due to chronic conditions, did not have weights obtained as ordered. The resident's care plan and physician's orders specified daily weights, but the last recorded weight was over a week prior to the survey. Interviews with staff revealed a lack of communication and documentation regarding the resident's weight monitoring, with the unit manager acknowledging the failure to obtain daily weights as ordered. Additional deficiencies included the failure to document weights for a resident with a history of diabetes and heart failure, despite orders for twice-weekly weights. The facility also did not implement physician orders for monitoring a peripheral IV site for another resident, and there were no orders or care plans for the care of a central line for a resident with lung cancer. These lapses in following physician orders and documenting care highlight significant gaps in the facility's adherence to professional standards of practice.
Medication Error Rate Exceeds Acceptable Limits
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 23.33% error rate observed during a survey. Three nurses were observed making seven errors out of 30 medication administration opportunities. These errors affected three residents, each with specific medical conditions. Resident #15, diagnosed with cancer, muscle weakness, and anxiety disorder, did not receive Aspirin and Magnesium Oxide as per the doctor's orders. Resident #22, with heart disease and stroke, received incorrect dosages of Senna, Ferrous Gluconate, and Folic Acid, and did not receive Famotidine. Resident #48, diagnosed with osteomyelitis, opioid dependence, and liver failure, received an incorrect dosage of Acetaminophen. The facility's policy on administering oral medications, revised in October 2010, was not adhered to, as nurses failed to confirm medication names and doses with the medication administration record (MAR). The Director of Nursing acknowledged that the medication error rate was above acceptable limits and emphasized that all medications should be administered as ordered by the physician. The report highlights the specific instances where the facility's procedures were not followed, leading to the observed medication errors.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly secured, as observed by surveyors. Medications were left unattended on medication carts, at nurses' stations, and in resident rooms. Specifically, medication cards containing gabapentin and duloxetine were found on an unlocked medication cart on the 1st floor, and medication cards with hyoscyamine, losartan, and famotidine were left unattended at the nurses' station. Additionally, medication cups with various medications were left on a resident's bedside table without supervision. On the 3rd floor, a medication cart was observed unlocked and unattended, with several staff members and a resident nearby. The Director of Nursing confirmed that medication carts should be locked when unattended. Furthermore, lidocaine patches were repeatedly found unattended at a resident's bedside, contrary to the facility's policy that they should be stored in the medication cart. The facility also failed to label medications with the date they were opened. A Wixela inhaler and a bottle of Tuberculin derivative were found open without a date, despite the manufacturer's instructions to discard them one month after opening. Additionally, a resident was found with a bottle of Motrin B at their bedside, although they had not been assessed for self-administration of medication. The resident admitted to placing the bottle in their backpack, and a nurse confirmed that the resident was not supposed to have medications at their bedside.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to accurately document care and treatment in the clinical records for four residents. For one resident with diabetes mellitus and dementia, the facility did not document diabetic foot care on multiple occasions as required by the physician's orders. The Director of Nursing confirmed that the documentation was incomplete for specific dates. Another resident with chronic obstructive pulmonary disease, heart disease, and kidney disease had inaccurate documentation regarding the change of oxygen tubing. The Medication Administration Record indicated that the tubing was changed on certain dates, but observations showed that the tubing was not replaced as documented. The Director of Nursing acknowledged that the documentation was incorrect. A third resident, who had a stroke and was dependent on others for activities of daily living, was observed without the prescribed hand splint. The resident reported that the splint had been missing for about a month, and the facility's records inaccurately indicated that the splint was in use. Additionally, a resident with cerebral infarction and vascular dementia had multiple instances where medication administration was not documented. The Director of Nursing stated that nurses are expected to document medication administration or refusals, which was not done in this case.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without a proper assessment. A resident, admitted with diagnoses including post-traumatic stress disorder, anxiety disorder, and depression, was observed with a bottle of Motrin B on their over-the-bed table. The resident admitted to placing the bottle in their backpack. The medical record did not show any assessment for the resident's ability to self-administer medication, nor was there a doctor's order or care plan for self-administration. A nurse confirmed that the resident was not supposed to have medications at bedside.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident was admitted with serious medical conditions, including osteomyelitis, a spinal abscess with drains, and was receiving intravenous antibiotics. Despite these needs, a review of the medical record showed that no baseline care plan was created within the specified timeframe, and even five days post-admission, the plan had not been developed. During an interview, the Director of Nursing acknowledged that the nursing staff should have created a baseline care plan within the required 48-hour period.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a resident-centered care plan for a resident with a history of stroke, diabetes, and depression, who was admitted in June 2023. The resident was dependent on assistance for activities of daily living (ADLs) and required a left hand splint and regular fingernail trimming to prevent injury. Despite a doctor's order and a care plan specifying the use of a hand brace and the need for nail trimming, the resident was observed without the hand brace and with long, jagged fingernails. The resident reported that the hand brace had been missing for about a month after being sent to laundry and not returned, and that staff had not assisted with nail trimming. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs. A CNA stated that it was their responsibility to cut fingernails and apply braces, while the Unit Manager was unaware of the resident's condition. The Physical Therapist admitted to mistakenly giving the resident's brace to another resident and failing to reorder it. Additionally, there was confusion about who was responsible for nail trimming, with the Unit Manager stating it was the podiatrist's role, while the DON indicated it was the CNAs' responsibility. The Unit Secretary confirmed that the resident had not been offered consent to see a podiatrist.
Failure to Review and Revise Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised by the interdisciplinary team as required. The facility's policy mandates that care plans be reviewed and updated at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. The resident in question was admitted with diagnoses including schizophrenia, anxiety disorder, and depression. An MDS was completed for the resident on October 22, 2024, but the care plan had not been reviewed since July 30, 2024, and the target dates for all goals had not been updated. During an interview, the Director of Nursing confirmed that care plans should be reviewed each time the MDS is completed, and new target dates should be set for all goals.
Failure to Assist Residents with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal care. Resident #14, who was admitted with schizophrenia, anxiety disorder, and depression, exhibited moderate cognitive impairment and required substantial assistance with personal hygiene. Despite this, the resident was observed multiple times with long, jagged fingernails and inch-long chin hair, which the resident expressed embarrassment about and stated they could not manage without staff assistance. The care plan indicated a need for assistance with daily hygiene, yet there was no indication of refusal of care by the resident. Resident #77, with a history of stroke, diabetes, and depression, was totally dependent on staff for ADLs due to impairments in both upper and lower body. The resident was observed with long, jagged fingernails and expressed a need for help, which had not been provided. The care plan required nails to be trimmed to prevent injury, but there was confusion among staff about responsibility for nail care, particularly for diabetic residents. Resident #15, diagnosed with cancer and muscle weakness, was also totally dependent on staff and was observed with significant chin hair, which the resident found embarrassing and stated they did not receive help to remove. These observations indicate a failure in the facility's adherence to its policy on supporting ADLs for dependent residents.
Failure to Provide Meaningful Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a meaningful activity program for a resident who was admitted with diagnoses including malignant neoplasm of the frontal lobe and aphasia. The resident was severely cognitively impaired, requiring assistance with daily activities and was primarily nonverbal. Despite having a care plan that included daily room visits and the use of an interpreter to address communication barriers, the resident was observed multiple times resting in bed without any engagement in activities. The resident's family member reported that staff did not offer in-room activities or turn on the TV or radio for the resident. Observations by the surveyor confirmed that the resident was often left in a dimly lit room with no active engagement from staff, as the TV and radio were not turned on. The Activities Director was unaware that the resident had not received in-room activities, despite having volunteers and staff available to provide such services. The Activity Participation Record showed no in-room activities provided on several dates, indicating a lack of adherence to the resident's care plan and a failure to meet the resident's needs for meaningful engagement.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident. The deficiency involved a resident with chronic obstructive pulmonary disease, heart disease, and kidney disease, who was observed receiving oxygen via nasal cannula attached to an oxygen concentrator. The oxygen tubing was dated over a month old, despite a doctor's order to change nasal cannula weekly and all disposable oxygen supplies every week. Additionally, the concentrator filter was observed to be covered with a gray fuzzy substance, indicating it had not been cleaned as required. The facility's policy on oxygen administration did not specify the frequency for changing tubing or cleaning the concentrator filter, and the Director of Nursing was unable to provide the manufacturer's instructions for cleaning the filter.
Inappropriate Pain Management Due to Incorrect Lidocaine Patch Application
Penalty
Summary
The facility failed to provide appropriate pain management for a resident by not adhering to the physician's orders regarding the administration of lidocaine patches. The resident, who was admitted with conditions including diabetes, atrial fibrillation, heart failure, and pain, was observed to have lidocaine 5% patches applied to the right hip and right shoulder, contrary to the physician's orders which specified the use of 4% patches on the left hip and right shoulder. This discrepancy was noted over several days, indicating a consistent failure to follow the prescribed pain management regimen. Interviews with nursing staff revealed a lack of adherence to the correct application of the lidocaine patches. Nurse #4 and Nurse #5 both confirmed the use of 5% patches, which was not in line with the physician's orders. The Director of Nursing acknowledged that the nursing staff should verify the correct strength and application site of the patches before administration. This oversight in following the prescribed pain management plan resulted in the resident not receiving the appropriate treatment as ordered by the physician.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD) upon admission. The facility's policy, revised in August 2022, mandates that individualized care plans addressing past trauma should be developed in collaboration with the resident and family, aiming to identify and decrease exposure to potential triggers. The resident, admitted in November 2024 with diagnoses including PTSD, osteomyelitis, spinal abscesses, and intravenous antibiotic use, did not have a baseline care plan for PTSD developed within 48 hours of admission. As of five days post-admission, the care plan was still not in place. Interviews with the Director of Nursing and the Regional Social Service Director confirmed that the nursing staff should have developed a baseline care plan for the resident's PTSD within 24 to 48 hours of admission.
Failure to Review and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to review and act upon the consultant pharmacist's recommendations for the monthly medication regimen reviews (MRR) for a resident. Specifically, the nursing staff and the physician did not review the pharmacist's recommendations for the resident in September and October. The facility's policy requires that the consultant pharmacist provide a written report to the attending physicians within 24 hours of the MRR, and if no action is taken, the pharmacist should contact the medical director or administrator. However, the Director of Nursing (DON) stated that he did not receive the pharmacy recommendations for these months, and the recommendations were not addressed by the nursing staff or the physician. The resident involved was admitted with diagnoses including diabetes, atrial fibrillation, heart failure, and pain, and was cognitively intact as per the Minimum Data Set (MDS) assessment. The pharmacist's progress notes recommended discontinuing certain medications due to nonuse and evaluating the continued need for another medication. Despite these recommendations, the active physician's orders still included the medications in question. Interviews with nursing staff revealed a lack of communication and follow-up on the pharmacy recommendations, with the Unit Manager acknowledging that the recommendations should have been reviewed and implemented by now.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control practices during a medication pass, as observed by a surveyor. Nurse #4 was seen pouring unit dose medications into her hand before transferring them to a medication cup, which could potentially contaminate the medications. Additionally, Nurse #4 poured medications from bottles into her bare hand, placed some into medication cups, and returned unused medications to the bottles, risking contamination of the medication bottles. During interviews, both Nurse #4 and the Director of Nursing acknowledged that medications should not be touched with bare hands, indicating a lapse in following the facility's infection control policy.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
