Care One At Lexington
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, Massachusetts.
- Location
- 178 Lowell Street, Lexington, Massachusetts 02420
- CMS Provider Number
- 225288
- Inspections on file
- 18
- Latest survey
- January 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Care One At Lexington during CMS and state inspections, most recent first.
The facility failed to maintain a homelike environment, with surveyors observing cracked paper towel holders, sagging ceiling tiles, worn furniture, and non-functional hand sanitizer units across several units. Interviews revealed lapses in reporting and addressing maintenance issues, as the Maintenance Director was unaware of some problems, and the Administrator emphasized the need for reporting broken equipment.
The facility failed to follow food service safety standards by allowing a cook to handle ready-to-eat baked potatoes with bare hands, violating the policy that requires gloves for such tasks. The Food Service Director acknowledged the error and indicated that the affected potatoes must be discarded.
The facility failed to ensure accurate documentation and compliance with physician orders for three residents. One resident was documented as wearing compression stockings that were never applied, another was not consistently provided with required heel protectors, and a third received a lidocaine patch without a specified application site. Staff were unaware of these orders, leading to inaccurate records and non-compliance.
The facility failed to follow infection control procedures, including improper cleaning of blood glucose meters, inadequate use of personal protective equipment, and expired hand sanitizers. Two nurses did not clean glucometers as per policy, and staff did not wear gowns or gloves in rooms requiring enhanced precautions. A CNA failed to perform proper hand hygiene, and expired hand sanitizers were found in multiple locations.
The facility failed to secure hallway handrails on the [NAME] and Minuteman units, with surveyors observing detached end caps and exposed screws. Maintenance staff acknowledged ongoing issues with loose handrails, and the facility's reporting system lacked records of these deficiencies. The Administrator expected immediate reporting and fixing of such issues, indicating a communication gap in maintenance processes.
A resident with cerebral palsy, Parkinson's disease, and tremors was observed struggling to eat meals without assistance, resulting in spills and undignified dining conditions. Despite the resident's visible difficulties and expressed need for help, staff did not check in or offer assistance during meals, leading to a deficiency in providing a dignified dining experience.
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in recorded assistance levels and discharge information. One resident's MDS did not match the documented assistance needs for daily activities, while another's discharge location was incorrectly recorded. These inaccuracies were acknowledged by the MDS nurse, indicating a failure in proper documentation.
The facility failed to implement physician orders and develop comprehensive care plans for residents, leading to deficiencies in care. A resident with congestive heart failure did not receive prescribed compression stockings, while another with diabetes did not have heel protector boots applied. A resident with cerebral palsy lacked a care plan for eating assistance, and another with a history of falls was not supervised adequately, despite being at risk. Staff were often unaware of these orders and care needs.
A resident was prescribed ascorbic acid ER for wound healing, but the facility did not stock this form. Nursing staff administered the medication 25 times without clarifying the order with the physician. The Unit Manager and DON acknowledged the need for clarification, highlighting a failure to adhere to medication administration policies.
A resident with cerebral palsy and malnutrition required moderate assistance with eating due to tremors and coordination issues. Despite this, the resident's care plan lacked details on the necessary assistance, and they were observed struggling to eat without staff help. Interviews revealed a communication gap between therapy and nursing departments, as therapy assessments were not accessible to nursing staff, leading to inadequate care.
A resident with a worsening wound condition did not receive appropriate wound care due to the facility's failure to obtain necessary treatment orders after a wound vac was placed on hold. Despite the resident's need for continued care, there were no documented orders for the use of Santyl or dressing changes, leading to confusion among nursing staff and inadequate wound management.
The facility failed to provide necessary treatment and services for pressure ulcers for two residents. One resident was admitted with a known deep tissue pressure injury but did not receive timely treatment or an air mattress. Another resident had an air mattress set incorrectly, contrary to physician orders, leading to inadequate pressure ulcer management. The facility's policies on pressure ulcer care were not followed, resulting in deficiencies in care.
A resident with a tracheostomy did not receive proper respiratory care, as their equipment was found soiled and improperly stored, leading to a deficiency. The RT was responsible for equipment changes but lacked specific orders, resulting in inconsistent maintenance. The DON confirmed the need for weekly changes, which were not adhered to.
The facility failed to ensure nursing staff were competent in medication administration, leading to deficiencies in care for residents. A nurse improperly used an insulin pen and administered enoxaparin without following guidelines, resulting in incorrect dosing and increased infection risk. Additionally, agency nurses lacked completed medication administration competencies, with no staff educator to oversee training.
A resident did not receive modafinil as ordered by the physician due to the facility's failure to follow its policy on unavailable medications. Despite the resident's report of inconsistent availability and lack of alternatives, staff interviews revealed uncertainty and inaction regarding the medication's unavailability.
The facility failed to address pharmacist recommendations for two residents. One resident's Depakote monitoring was not implemented, and another's Trazodone prescription lacked a stop date despite physician approval. Staff interviews confirmed these oversights in medication management.
Two residents in an LTC facility experienced significant medication errors related to insulin administration. One resident did not receive insulin before breakfast as ordered, leading to hyperglycemia, while another received an inaccurate dose due to a failure to prime the insulin pen. These errors were due to staff not following physician orders and medication protocols.
The facility failed to properly store and label medications, as observed in an unlabeled medication cup in a cart and an unlocked treatment cart with unattended supplies. Additionally, a vial of Tuberculin was incorrectly labeled with an expiration date beyond the manufacturer's 30-day guideline.
A facility failed to obtain a resident's Depakote serum drug level as ordered by the physician, resulting in a 16-month lapse in testing. The resident, with major depression and traumatic brain injury, had orders for biannual Depakote level checks, but the facility did not document these tests. Staff interviews revealed scheduling errors in the electronic health record and a lack of confirmation for lab slips, leading to the oversight.
A resident with celiac disease was served gluten-containing foods due to a failure in the facility's tray ticket system, which did not reflect the resident's gluten allergy. The resident's medical record indicated a gluten allergy, but the system error led to the resident being served pasta, bread, and gravy containing gluten, contrary to their dietary needs.
The facility failed to post daily nurse staffing information as required, omitting the facility census and total number and hours for RNs, LPNs, and CNAs. Observations showed outdated and incomplete postings, and interviews revealed staff were unaware of the full requirements. The Director of Nursing and Administrator acknowledged the need for compliance.
The facility did not notify the State Agency of a change in the Director of Nursing (DON) position as required by policy. The new DON had been in the role for over a month, but the facility failed to submit the necessary notice to the Health Care Facility Reporting System. The Administrator acknowledged the oversight, admitting that the change was not reported despite the policy requiring notification at least fourteen days prior to the change.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment across several units, as observed by surveyors. On the [NAME] unit, issues included cracked plastic paper towel holders in multiple rooms and the hallway men's room, sagging and broken ceiling tiles in several rooms, worn dressers, and a broken bathroom wall. On the [NAME] unit, surveyors noted cracks in the wallpaper, a call light device hanging by an electrical cord, and a closet door falling off its hinges. The Minuteman unit had dressers with missing laminate, chipped wood and scratched paint on door trims, sagging ceiling tile trim, and non-functional hand sanitizer units. Interviews with the Maintenance Director revealed that while there is a maintenance tracking program in place, not all issues were reported by staff, leading to some being unaddressed. The Maintenance Director was aware of some issues but not others, such as the broken paper towel holders and bathroom wall. The Administrator confirmed that broken or non-functional equipment should be reported and addressed, indicating a lapse in communication and reporting within the facility's maintenance processes.
Improper Handling of Ready-to-Eat Food
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by allowing staff to handle ready-to-eat food with their bare hands. During a tray line observation, a cook was seen using his bare hands to transfer four ready-to-eat baked potatoes from the steam table onto plates intended for residents. This action was in direct violation of the facility's policy, which prohibits contact between food and bare hands and mandates the use of gloves when handling ready-to-eat food. The Food Service Director confirmed that the cook should not have touched the potatoes with his bare hands and stated that all the potatoes touched by the cook must be discarded.
Inaccurate Documentation and Order Compliance Issues
Penalty
Summary
The facility failed to ensure accurate documentation of the clinical records for three residents. For one resident with congestive heart failure and bilateral leg edema, the facility documented that compression stockings were applied daily, despite observations and staff interviews indicating that the resident never wore them. The CNA and nurse responsible for the resident were unaware of the physician's order for the stockings, and the Director of Nurses confirmed that the documentation was inaccurate. Another resident with diabetes and peripheral vascular disease was supposed to wear heel protector boots at all times, as per physician's orders. However, observations revealed that the resident was often without the boots, and staff interviews indicated a lack of awareness of the order. The resident reported that the left boot was lost and not replaced properly, leading to its non-use for several months. The Director of Nurses acknowledged that the physician's orders were not being followed. For a third resident with chronic pain, the facility failed to obtain a complete physician's order for a lidocaine patch, which lacked a specified application site. The nursing staff administered the patch without documenting the location, and the Unit Manager confirmed the order was incomplete. The Director of Nursing stated that the order should have included a location for application.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control procedures, as evidenced by multiple observations and interviews. Two nurses did not clean blood glucose meters according to the facility's policy. One nurse placed a glucometer back into its case without cleaning it after use, while another used an alcohol wipe instead of a germicidal wipe due to unavailability. The Director of Nursing confirmed that the glucometers should be cleaned with germicidal wipes after each use. Additionally, staff did not wear complete personal protective equipment in rooms requiring enhanced barrier precautions. A nurse was observed taking vital signs from a resident receiving enteral nutrition without wearing a gown or gloves and did not disinfect the equipment between uses. The Director of Nursing stated that residents on enteral nutrition should be on enhanced barrier precautions, and staff should wear gloves and gowns during high-contact activities. The facility also failed to ensure proper hand hygiene and glove use. A CNA was seen wearing gloves in the hallway and did not wash hands after removing them, potentially contaminating surfaces. Furthermore, expired hand sanitizer was found in multiple wall-mounted units throughout the facility. The Director of Housekeeping and the Administrator acknowledged that expired hand sanitizer should not be in use and should be replaced by housekeeping staff.
Facility Fails to Secure Hallway Handrails
Penalty
Summary
The facility failed to ensure that hallway handrails were securely fastened on the [NAME] and Minuteman units. Observations by the surveyor revealed multiple instances of detached handrail end caps and exposed metal screws in various locations, including near rooms 223-224, the sprinkler room, and the dining room. These deficiencies were noted during a series of observations conducted on 12/27/24 and 12/30/24. Interviews with maintenance staff revealed that the issue of loose handrails was ongoing, with the Maintenance Director acknowledging that he had noticed missing end caps about a week prior but had not yet ordered replacements. The facility's online TELS program, which is used to report maintenance issues, did not contain any records of the broken or missing handrails. Additionally, a preventative maintenance worksheet indicated that handrails needed fixing but lacked a completion date. The Administrator expressed an expectation that such issues should be reported and addressed immediately, highlighting a gap in communication and follow-up within the facility's maintenance processes.
Failure to Provide Dignified Dining Experience for Resident with Eating Difficulties
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with multiple medical conditions, including cerebral palsy, Parkinson's disease, and tremors, which affect their ability to eat independently. The resident, who has moderately impaired cognition, was observed struggling to eat meals without assistance. During breakfast, the resident attempted to eat scrambled eggs using a weighted utensil but was unable to gather food onto the utensil due to tremors. The resident resorted to using their mouth and hand to eat directly from the plate, resulting in food spilling onto their clothing and the floor. Similarly, during lunch, the resident had difficulty bringing a juice cup to their mouth, causing spills. Throughout both meals, staff did not check in or offer assistance, despite the resident's visible struggle and expressed desire for help. Interviews with staff revealed that the resident is typically set up for meals but sometimes requires assistance due to their tremors. Staff members acknowledged that they should be offering help and checking in during meals to ensure the resident can eat. The Director of Nursing confirmed that staff should not leave the resident without ensuring they can access and consume their meal, and they should encourage and offer assistance as needed. However, during the observed meals, these actions were not taken, leading to the deficiency in providing a dignified dining experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in the recorded levels of assistance required. Resident #4, who was admitted with diagnoses including dementia, bipolar disorder, and anxiety disorder, had inconsistencies between the facility's Documentation Survey Report and the MDS. The Documentation Survey Report indicated that Resident #4 required substantial to maximum assistance for eating, oral hygiene, and upper body dressing, while the MDS inaccurately recorded these needs as requiring only supervision or partial assistance. This discrepancy was acknowledged by MDS Nurse #1, who confirmed that the MDS should reflect the daily documentation completed by the Certified Nurse's Aides (CNAs). Similarly, Resident #139, admitted with conditions such as cellulitis, diabetes, and malnutrition, was discharged home with medications and family, as noted in the progress notes. However, the MDS inaccurately documented the discharge location as an acute care hospital. MDS Nurse #1 admitted that the MDS was not coded correctly and should have accurately reflected the resident's actual discharge location. These inaccuracies in the MDS assessments highlight a failure in ensuring that the residents' needs and discharge information were correctly documented, as per the facility's documentation and procedures.
Failure to Implement Care Plans and Physician Orders
Penalty
Summary
The facility failed to implement physician orders and develop comprehensive care plans for several residents, leading to deficiencies in care. For one resident with chronic congestive heart failure and bilateral leg edema, the facility did not implement the physician's order for compression stockings. Despite documentation indicating that the stockings were applied and removed daily, observations and staff interviews revealed that the resident was not wearing them, and staff were unaware of the order. Another resident with diabetes and peripheral vascular disease did not receive the prescribed heel protector boots. Observations showed the resident's heels resting on the mattress without the boots, and staff interviews confirmed a lack of awareness of the physician's order. The resident reported that the boots were not applied due to a lost boot and an ill-fitting replacement, leading to staff discontinuing their application. Additionally, a resident with cerebral palsy and malnutrition did not have a care plan for eating assistance, despite requiring moderate assistance due to tremors. Observations showed the resident struggling to feed themselves without staff assistance, resulting in significant food spillage. Lastly, a resident with cerebral palsy and a history of falls did not have a comprehensive falls care plan. The resident was observed sliding out of their wheelchair without supervision, and staff interviews indicated a lack of awareness of the need for continuous supervision, despite the resident's known fall risk.
Failure to Clarify Medication Order for Resident
Penalty
Summary
The facility failed to meet professional standards of practice for a resident due to a lack of clarification regarding a physician's order for ascorbic acid extended release (ER) oral capsule. The resident, who was admitted with diagnoses including diabetes, chronic pain, and colitis, was prescribed ascorbic acid ER for wound healing. However, the facility did not stock this form of the medication. Despite this, nursing staff documented administering the medication 25 times over a period of 11 days without clarifying the order with the physician or adjusting to the available form of the medication. During the survey, it was observed that a nurse was unaware of the ascorbic acid ER form and noted that the pharmacy had not delivered it. The Unit Manager and Director of Nursing both acknowledged that the nursing staff should have clarified the order with the physician and adjusted to the form of the medication on hand. This oversight indicates a failure to adhere to the facility's medication administration policy, which requires verification and clarification of medication orders to ensure safe and appropriate administration.
Failure to Assist Resident with Eating Due to Communication Gap
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with cerebral palsy and malnutrition. The resident, who was cognitively intact, required moderate assistance with eating due to impairments in balance, fine motor coordination, and strength, as well as a bilateral upper extremity tremor. Despite these needs, the resident's care plan did not outline the level of assistance required for eating, and the resident was observed struggling to feed themselves without staff assistance. Observations by the surveyor revealed that the resident was left alone during meal times, resulting in significant portions of food being dropped and not consumed. This lack of assistance was consistent over multiple days, with the resident visibly struggling to manage eating independently due to their tremors. Interviews with the resident confirmed their need for assistance, as they expressed difficulty in keeping food on the spoon due to worsening tremors. Interviews with facility staff, including a nurse, occupational therapist (OT), and the Director of Nursing (DON), highlighted a communication gap between the therapy and nursing departments. The OT had assessed the resident's need for assistance and expected this to be reflected in the care plan, but the information was not accessible to nursing staff due to being stored in a separate software system. The DON acknowledged that the care plan should have included the level of assistance required, as determined by the OT, but this was not implemented, leading to the deficiency in care provided to the resident.
Failure to Obtain Wound Care Orders for Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a worsening wound condition. The resident, who was admitted with osteomyelitis, diabetes, and peripheral vascular disease, had a wound vac placed on hold due to maceration and worsening of the wound. Despite the need for continued wound care, the facility did not obtain new wound care orders for five days after the wound vac was stopped. During this period, the resident reported that nursing staff applied Santyl daily, but there were no documented orders for this treatment in the resident's medical records. The resident expressed concerns that nursing staff were unsure of the appropriate wound care procedures due to the lack of orders. Interviews with the unit manager and the director of nursing confirmed that there were no orders for the use of Santyl or for dressing changes while the wound vac was on hold, which should have been obtained. The resident's medical records and treatment administration records did not include necessary orders for the period when the wound vac was not in use, leading to a lapse in proper wound care management.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident #441 was admitted with a known deep tissue pressure injury (DTPI) on the coccyx, but the facility did not place an order for treatment or monitoring of the wound upon admission. Despite the presence of a dressing on the wound, nursing staff were unaware of the injury, and no treatment orders were initiated until after the surveyor's intervention. The resident was also not provided with an air mattress until three days post-admission, contrary to the physician's expectations. Resident #119, who had severe cognitive impairment and a history of pressure injuries, was observed with an air mattress set incorrectly at 200 pounds, despite physician orders specifying a setting of 150 pounds. The resident's care plan and physician's orders were not consistently implemented, leading to the resident being at risk for further skin breakdown. Observations revealed that the resident's buttocks were red, macerated, excoriated, and had open areas, indicating inadequate pressure ulcer management. The facility's policies on pressure ulcer care and support surface guidelines were not adhered to, resulting in a lack of appropriate interventions for residents at risk of skin breakdown. The Director of Nursing acknowledged that the air mattress settings should have been adjusted according to the physician's orders, and that treatment orders should have been in place for Resident #441's DTPI upon admission.
Failure to Maintain Clean Respiratory Equipment for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, leading to a deficiency in maintaining the cleanliness and sanitation of the resident's respiratory equipment. The resident, who was admitted with diagnoses including malignant neoplasm of the mouth, dysphagia, and COPD, required tracheostomy care as indicated in their plan of care. During an observation, the surveyor noted that the resident's tracheostomy mask and respiratory equipment were visibly soiled with dried secretions and were improperly stored on a cart with various other items, which could lead to potential contamination and infection. Interviews with facility staff, including a nurse, unit manager, and respiratory therapist (RT), revealed that the RT was responsible for managing the respiratory equipment. However, the RT did not have specific physician's orders for changing the equipment and stated that changes were typically made weekly, or sooner if necessary. The Director of Nursing confirmed that the equipment should be changed weekly and dated accordingly. The observations and interviews highlighted a lapse in maintaining the cleanliness and timely replacement of respiratory equipment, contributing to the deficiency.
Nursing Competency Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide adequate care for residents, as evidenced by multiple deficiencies observed during the survey. For one resident with diabetes and other medical conditions, a nurse was observed using an insulin pen without priming it, resulting in an incorrect insulin dose. Additionally, the nurse did not clean the insulin pen with alcohol before use, increasing the risk of infection. The nurse admitted to being unaware of the need to prime the pen or clean it with alcohol, and the Director of Nursing confirmed that the nurse should have been competent in these procedures. In another instance, the same nurse demonstrated a lack of competency in administering enoxaparin, a medication used to thin blood. The nurse struggled to locate and prepare the medication, and ultimately administered it without cleaning the injection site, which led to immediate bruising. The nurse also mishandled the syringe, walking with an exposed needle, which posed a risk to staff and residents. The Director of Nursing acknowledged that the nurse should have been competent in administering enoxaparin but was not. Furthermore, the facility failed to ensure that agency nursing staff were adequately trained and demonstrated competency in medication administration techniques. The surveyors identified multiple concerns, including the failure to clean a glucometer and improper use of an insulin pen. A review of staff education files revealed that none of the nurses with identified concerns had completed medication administration competencies. The facility lacked a staff educator to oversee the completion of required orientation packets for agency nurses, contributing to the deficiencies observed.
Failure to Provide Routine Medication to Resident
Penalty
Summary
The facility failed to provide routine medications to a resident, specifically modafinil, as ordered by the physician. The resident, who was admitted with diagnoses including anxiety, depression, ADHD, and dysphagia, reported that the nursing staff did not consistently have the medication available and did not offer any alternatives when it was unavailable. The facility's policy on unavailable medications requires the pharmacy to notify nursing staff when medications are unavailable and suggest alternatives, while nursing staff are to inform the attending physician and obtain new orders. However, these steps were not followed, leading to the resident missing multiple doses of modafinil over several days. Interviews with facility staff revealed a lack of clarity and action regarding the unavailability of the medication. The Unit Manager was unsure why the medication was not administered, suggesting it might have been back-ordered, while the Director of Nursing acknowledged that the medication should have been available and that alternative methods could have been used to obtain it. Despite the facility's policy, there was no evidence that the nursing staff notified the physician or sought alternative medications, resulting in a failure to meet the resident's pharmaceutical needs.
Failure to Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to address recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist for two residents. For Resident #14, who was admitted with diagnoses including major depression and traumatic brain injury, the facility did not act on the pharmacist's recommendation to monitor Depakote levels and liver function tests. Despite the pharmacist's note dated 11/6/24, the recommendation was not addressed, and the Unit Manager did not recall receiving the MMR for November 2024. For Resident #29, who was admitted with conditions such as osteomyelitis, diabetes, and peripheral vascular disease, the facility did not implement the pharmacist's recommendation regarding the Trazodone prescription. The pharmacist noted on 12/8/24 that the Trazodone order needed a duration, and the attending physician agreed to a 14-day extension. However, the order was not updated with a stop date, and the Unit Manager was unsure why the MMR was not implemented by nursing. Interviews with facility staff, including the Director of Nursing, confirmed that the MMRs should have been addressed and implemented. The failure to act on these recommendations indicates a lapse in the facility's medication management processes, impacting the care provided to the residents involved.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident #29, the nursing staff did not administer insulin as per the physician's order. The resident, who was admitted with conditions including diabetes, reported not receiving insulin before breakfast, as required. The nurse responsible was unaware of the resident's diabetic status and failed to check blood sugar levels or administer insulin on time. This resulted in the resident experiencing symptoms of hyperglycemia, with a blood sugar level of 345 recorded after breakfast, nearly four hours past the scheduled insulin administration time. For Resident #391, the nursing staff failed to prime the insulin pen injector before administering insulin, leading to an inaccurate dose. The resident, who was admitted with diabetes and other conditions, was observed receiving insulin glargine without the pen being primed. The nurse involved was not aware of the need to prime the insulin pen, which is a critical step to ensure the correct dosage is delivered. This oversight was acknowledged by the Director of Nursing, who confirmed that the pen should have been primed to ensure the resident received the correct dose. Both incidents highlight a failure to adhere to established medication administration protocols, as outlined in the facility's policies and the manufacturer's guidelines for insulin pen use. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors, indicating lapses in the nursing staff's adherence to physician orders and medication administration procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in several instances. On the [NAME] Unit, a medication cart was found to contain an unlabeled medication cup with 10 pills. Nurse #2 admitted to placing the cup in the cart after running out of an over-the-counter medication and leaving the unit to retrieve more. This indicates a lack of awareness regarding the prohibition of storing unlabeled medications in the cart. Additionally, a treatment cart was found unlocked and unattended between resident rooms, with wound supplies left on top. Nurse #1 acknowledged that the cart should have been locked and supplies should not have been left unattended. In the medication storage room, an opened vial of Tuberculin, Purified Protein Derivative, was found with an incorrect expiration date. The vial was labeled with an open date of 12/28/24 and an expiration date of 3/22/25, despite manufacturer instructions to discard it 30 days after opening. Nurse #2 was unsure of the correct duration, while Unit Manager #2 confirmed the 30-day guideline. The Director of Nurses reiterated the importance of proper dating. These observations highlight lapses in adherence to medication storage and labeling protocols.
Failure to Obtain Depakote Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided for a resident, specifically in obtaining the Depakote serum drug level as ordered by the physician. The resident, who was admitted with diagnoses including major depression and traumatic brain injury, had a physician's order for Depakote level checks every six months. However, the facility did not document the completion of these tests in accordance with the physician's orders and the resident's plan of care. The last recorded Depakote level was from August 2023, and no further results were documented, indicating a lapse of 16 months without the required testing. Interviews with facility staff revealed that the orders for the Depakote levels were not scheduled correctly in the electronic health record, and there was a failure to confirm that lab slips were in place for the tests. Nurse #4 admitted to not confirming the completion of the Depakote levels, and Unit Manager #3 acknowledged that nursing should have followed the physician's orders. The Director of Nursing also confirmed that the Depakote levels should have been obtained as ordered.
Failure to Accommodate Gluten Allergy for Resident with Celiac Disease
Penalty
Summary
The facility failed to provide food that accommodated the allergies and dietary needs of a resident with celiac disease, a condition that requires a strict gluten-free diet. Despite the resident's medical record clearly indicating a gluten allergy and an active diagnosis of celiac disease, the facility served the resident food containing gluten. This included pasta made from semolina and durum wheat, as well as bread and gravy thickened with flour, all of which were observed being consumed by the resident during meal times. The deficiency was attributed to a failure in the facility's tray ticket system, which did not reflect the resident's gluten allergy due to an incorrect categorization upon admission. The Food Service Director confirmed that the system should have automatically populated the allergy information from the resident's electronic health records, but it did not. Consequently, the resident was served gluten-containing foods, contrary to their dietary restrictions, as confirmed by both the cook and the Registered Dietitian.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the regulatory requirement to post daily nurse staffing information at the start of each shift. Specifically, the facility did not consistently post the facility census, total number, and hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) as required. Observations by the surveyor on two separate occasions revealed that the posted staffing information was outdated and incomplete, lacking essential details such as the facility census and the total number and hours for RNs, LPNs, and CNAs. Interviews with facility staff, including the Receptionist, Staffing Coordinator, Director of Nursing, and Administrator, highlighted a lack of awareness and adherence to the posting requirements. The Staffing Coordinator admitted to being unaware of the need to include the facility census and total staffing numbers and hours in the postings. The Director of Nursing and Administrator acknowledged that the postings should meet regulatory standards, indicating a gap in communication and training regarding compliance with staffing information regulations.
Failure to Notify State Agency of Change in Director of Nursing
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the Director of Nursing (DON) position. According to the facility's policy, the governing board is required to notify the state-licensing agency of any changes in the administrator or director of nursing services. This notification should be provided at least fourteen days prior to the change taking effect, including details such as the name and license number of the new DON, the effective date of the change, and any other necessary information. However, during a review of the Health Care Facility Reporting System (HCFRS) on December 26, 2024, it was found that the facility did not submit the required notice of the change in the DON position. Interviews conducted during the survey revealed that the new DON, who had been in the role for over a month, was unaware that the facility had not reported the change in her status. The Administrator admitted during an interview that he failed to report the change to the State Agency, acknowledging that the new DON's start date was November 4, 2024. This oversight resulted in a deficiency as the facility did not comply with the established policy and state regulations regarding the notification of changes in key administrative personnel.
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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