Care One At Lowell
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 19 Varnum Street, Lowell, Massachusetts 01850
- CMS Provider Number
- 225224
- Inspections on file
- 20
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Care One At Lowell during CMS and state inspections, most recent first.
The facility did not ensure that required physician visits were completed on schedule for several residents, resulting in missed or delayed face-to-face assessments by the physician or nurse practitioner. Some residents were only seen upon admission, while others experienced significant gaps between visits, contrary to regulatory requirements. Staff interviews confirmed lapses and confusion regarding the mandated visit schedule.
A resident with diabetes and other chronic conditions had physician orders to hold insulin if blood sugar was 200 or below, but nursing staff documented insulin administration in the MAR on multiple occasions when blood sugar was below this threshold. Interviews confirmed that the resident was actively involved in their care and would not have allowed insulin to be given under these circumstances, and staff acknowledged the documentation was inaccurate.
A resident with epilepsy and a history of heart attack experienced a leaking bathroom sink for about two months, with the issue repeatedly reported to staff but not documented or addressed. The resident had to empty a basin collecting the leak, and staff interviews confirmed the problem was known but not communicated to maintenance as required.
A resident with Huntington's disease and moderate cognitive impairment was discharged from hospice services, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS as required. The care plan and nursing notes continued to reference hospice care after discharge, and staff confirmed the assessment was not completed within the mandated timeframe.
A resident with a gastrostomy tube did not have their water flush bag changed every 24 hours as required by facility policy, with the same bag remaining in use for over 62 hours. Nursing staff were unclear about shift responsibilities for changing the bag, and there was no documentation explaining the lapse.
A resident with cardiac and pulmonary conditions was observed receiving oxygen therapy via a face mask at 3L/min, contrary to the physician's order for 2L/min via nasal cannula. Staff interviews confirmed that oxygen should be administered according to the physician's order, but the observed practice did not match the prescribed method or flow rate.
Two residents experienced medication errors when nurses administered an incorrect dose of atorvastatin and gave aspirin without a specified dosage, resulting in a medication error rate above 5%. Both the nurses and the DON acknowledged that medications were not administered according to complete and accurate physician orders.
A resident with a history of traumatic subdural hemorrhage and paraplegia reported genital pain, leading to a physician's order for an ultrasound. The ultrasound was performed, but the results were not filed in the clinical record, reviewed by staff, or reported to the attending physician as required by facility policy. Staff were unaware of the missing results until prompted by a surveyor.
The facility did not provide required written transfer/discharge and bed hold notices to three residents, including individuals with significant physical and cognitive needs, during multiple hospitalizations. The Social Worker confirmed that these notifications were not completed when she was not present.
The facility did not perform a Massachusetts Nurse Aide Registry background check for a CNA before hiring, as required by their policy. The policy mandates background checks to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. Despite attempts by the HR department, the necessary documentation was not found.
A facility failed to monitor and assess the use of thigh bands as a potential restraint for a resident with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired, was observed in a Broda chair with straps preventing them from exiting. The facility's records did not indicate the use of restraints, and the Occupational Therapy Discharge Summary did not specify the use of thigh bands while lying flat. Interviews revealed that the straps were used to prevent the resident from exiting the chair, and the use of thigh bands should have been evaluated and care planned.
A facility failed to create a care plan for a resident with migraines, despite pre-admission paperwork and a physician's order indicating the condition. The resident, who is cognitively intact, reported daily migraines and wearing sunglasses for relief. Interviews with staff revealed they were unaware of the resident's migraines, highlighting a gap in communication and care planning.
The facility failed to obtain a doctor's order for the transfer of two residents. One resident with Huntington's disease, schizophrenia, and depression was transferred to the hospital without authorization. Another resident with alcohol dependence and cirrhosis was discharged home without a doctor's order. The DON confirmed that orders should have been obtained for both transfers.
The facility failed to provide trauma-informed care for two residents with PTSD by not conducting proper trauma assessments and not developing personalized care plans. One resident's care plan lacked details on re-traumatization triggers and interventions, while another's did not include specific traumatic events or identified triggers. The social worker and DON acknowledged the lack of personalized care planning.
A resident with cognitive intactness and dental issues, including cavities and broken teeth, did not receive necessary dental care despite documented pain and a physician's order. The facility's staff, including the DON, were unaware of the resident's condition, and the resident relied on over-the-counter medication provided by family for pain relief. The facility's policy for routine and emergency dental services was not followed, resulting in a deficiency.
A housekeeper failed to follow hand hygiene protocols by wearing the same gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. Facility policies require gloves to be removed and hands sanitized between tasks, which was not adhered to, leading to a deficiency in infection control.
A resident was inaccurately coded in the MDS assessment as using a trunk restraint, despite being observed ambulating independently without any restraint. The resident's medical record did not support the use of a restraint, and interviews with staff confirmed the coding error.
Failure to Complete Timely Physician Visits for Multiple Residents
Penalty
Summary
The facility failed to ensure that required physician visits were completed in a timely manner, as mandated by state and federal regulations. Specifically, several residents did not receive face-to-face visits from their attending physician or nurse practitioner within the required intervals following admission. For example, three residents were only seen by the physician upon admission and did not have subsequent visits every 30 days as required for new admissions. Another resident was not seen by the physician until approximately three months after admission, with the next visit by the nurse practitioner occurring several months later. Additionally, for four other residents, the facility did not ensure that physician visits were conducted as required. In these cases, residents were either seen only once by the physician or had irregular visits from the nurse practitioner, with significant gaps between visits. Some residents reported not having seen the physician or nurse practitioner in a considerable amount of time. Review of progress notes confirmed these lapses, with documentation showing missed or delayed visits that did not meet the regulatory schedule. Interviews with staff, including the ADON, unit manager, nurse practitioner, and physician, revealed inconsistencies in understanding and implementing the required visit schedule. Staff acknowledged that some residents may have been missed for visits due to oversight, and there was confusion regarding the frequency of required visits, particularly for new admissions. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, but this was not consistently followed for the sampled residents.
Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to accurately document the administration of insulin for one resident with diabetes, chronic kidney disease, and congestive heart failure. The resident had physician orders specifying that all insulin should be held if fasting blood sugar was 200 or below. Despite this, the Medication Administration Records (MAR) for April and May indicated that insulin was documented as administered on multiple occasions when the resident's blood sugar was below the specified threshold. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident was highly involved in their insulin management and would not allow insulin to be administered if their blood sugar was below 200. Nurses, including the one who documented the administrations, acknowledged that insulin should not have been documented as given when it was not, and that the documentation was inaccurate. A review of the facility's charting and documentation policy indicated that all documentation should be objective, complete, and accurate. However, there was no clarifying information in the nursing progress notes regarding whether insulin was actually administered or held on the dates in question, leading to a failure to maintain accurate medical records in accordance with professional standards.
Failure to Repair Leaking Sink and Ensure Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for one resident by not repairing a leaking bathroom sink for approximately two months. The resident, who was cognitively intact and had diagnoses including epilepsy and a history of heart attack, reported the issue to staff multiple times. The sink was observed to be actively leaking into a plastic basin, which the resident had to empty personally, and the water in the basin was discolored. The resident expressed that the situation was unpleasant and attracted bugs. Staff interviews revealed that a CNA was aware of the leaking sink for over a month but did not document the issue in the maintenance log as required. The maintenance log contained no record of the problem, and the Unit Manager was unaware of any maintenance requests or emails regarding the sink. The Maintenance Director confirmed he was not notified of the issue until the surveyor brought it to the attention of the Unit Manager. The DON acknowledged that maintenance should have been notified immediately and that waiting over a month was unacceptable.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was discharged from hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA comprehensive assessment must be completed within 14 days following a significant change in a resident's status. The resident in question had diagnoses including Huntington's disease and hypertension, and was noted to have moderate cognitive impairment. The most recent MDS assessment indicated the resident was receiving hospice services, but documentation showed the resident was discharged from hospice on 4/30/25. Despite the discharge from hospice, the resident's care plan continued to reference hospice care, and nursing progress notes inaccurately documented that the resident was still receiving hospice services after the discharge. A review of the medical record confirmed that no SCSA was completed within the required timeframe. Interviews with facility staff, including the MDS Nurse and DON, confirmed awareness of the requirement and acknowledged that the assessment was not completed as mandated.
Failure to Change Water Flush Bag Every 24 Hours for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube by not changing the water flush bag every 24 hours as required by facility policy. The resident, who had severe cognitive impairment and was rarely or never understood, was receiving tube feedings and scheduled water flushes through an enteral feeding pump. Observations revealed that the water flush bag in use had not been changed for over 56 hours, and subsequent review showed it remained unchanged for more than 62 hours. The facility's policy specified that open system bags and tubing may hang for up to 24 hours unless compromised, but this was not followed in the resident's care. Interviews with nursing staff and facility leadership confirmed that water flush bags should be changed every 24 hours, typically when a new tube feeding container is connected. However, both night and evening shift nurses believed it was the other shift's responsibility to change the bag, resulting in the task being overlooked. There was no documentation in the resident's nursing progress notes to explain the failure to change the water flush bag as required, and physician orders did not specify the frequency for changing the water flush bag.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident. Specifically, the resident had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, multiple observations over several days showed the resident receiving oxygen at 3 liters per minute via a face mask, which did not match the physician's order regarding both the delivery method and the flow rate. The facility's policy on oxygen administration requires verification and adherence to physician orders, including the specific device and flow rate. The resident involved had a history of chronic diastolic heart failure, primary pulmonary hypertension, and sleep apnea, and was cognitively intact according to the most recent assessment. Despite the care plan and physician's orders specifying oxygen administration via nasal cannula at a set rate, staff were observed providing oxygen through a different device and at a higher flow rate. Interviews with nursing staff and the Director of Nurses confirmed that oxygen should be administered exactly as ordered by the physician, both in terms of device and flow rate.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed out of 26 opportunities, resulting in a 7.69% error rate. For one resident with hypertension and hyperlipidemia, a nurse administered an incorrect dose of atorvastatin calcium, giving only 10 mg instead of the prescribed 20 mg. The nurse acknowledged the error, stating that the dose had recently been increased and she should have administered two tablets to meet the new order. The Director of Nursing confirmed that the medication was not administered according to the physician's order. In another instance, a nurse administered a chewable aspirin tablet to a resident with hyperlipidemia and atrial fibrillation without verifying the dosage, as the physician's order did not specify the required dosage. The nurse admitted that all medication orders should include a dosage and that the aspirin should not have been given without clarification. The Director of Nursing also confirmed that the order was incomplete, lacking the necessary dosage information.
Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.
Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation related to transfer/discharge notices and bed hold policies for three residents who experienced hospitalizations. For one resident with paraplegia and communicating hydrocephalus, who was cognitively intact and fully dependent on staff for daily activities, the clinical record showed multiple hospital transfers without any indication that transfer or bed hold notices were provided. Similarly, another cognitively intact resident with osteomyelitis and blindness was transferred to the hospital, but the clinical record did not show that the required notices were given. A third resident, who had severe cognitive impairment and could not participate in mental status interviews, was hospitalized three times, yet there was no documentation that transfer/discharge notices were provided to the resident or their representative. In interviews, the Social Worker confirmed that these notices were not completed and stated that the process does not occur in her absence.
Failure to Conduct Required Background Check for CNA
Penalty
Summary
The facility failed to conduct a Massachusetts Nurse Aide Registry background check for a Certified Nurse Aide (CNA) before hiring, as required by their policy. The policy, dated March 2019, mandates that background checks be completed prior to employment to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. CNA #1 was hired on June 7, 2022, but there was no documentation in his personnel file to confirm that the required background check was conducted. During interviews, the facility's Administrator, Director of Nurses (DON), and Assistant Director of Nurses acknowledged that they could not locate the background check for CNA #1, despite ongoing attempts by their offsite Human Resource department.
Failure to Monitor and Assess Use of Potential Restraint
Penalty
Summary
The facility failed to monitor and assess the use of equipment being used as a potential restraint for a resident diagnosed with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired and totally dependent for all activities of daily living, was observed multiple times in a Broda chair with bilateral padded straps that prevented them from exiting the chair. The facility's policy on restraints requires that any restraint used must be the least restrictive device possible and used for the least amount of time necessary to treat medical symptoms. However, the medical record, doctor's orders, and care plan for the resident did not indicate the use of a restraint or thigh bands. The facility's Occupational Therapy Discharge Summary noted that thigh bands were used to prevent forward sacral sliding and promote skin integrity, but did not specify their use while the resident was lying flat. The Pre-Restraining Evaluation indicated that the thigh bands provided positional support without preventing volitional movements, but did not address their appropriateness when the resident was lying flat. The Physical Restraint Elimination Review failed to evaluate the use of thigh bands for purposes other than those recommended by Occupational Therapy. Interviews with the Unit Manager and Director of Nursing revealed that the straps were used to prevent the resident from exiting the chair and that the use of thigh bands while lying flat should have been evaluated, care planned, and ordered by a doctor.
Failure to Develop Care Plan for Resident's Migraines
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident suffering from migraine headaches. Despite the resident's pre-admission paperwork indicating a history of migraines and a physician's order for Excedrin Migraine, the resident's care plans and medical records did not reflect this condition. The resident, who is cognitively intact, reported experiencing daily migraines and wearing sunglasses to alleviate symptoms, yet this information was not incorporated into their care plan. Interviews with facility staff, including a CNA, Unit Manager, and the Director of Nurses, revealed a lack of awareness regarding the resident's migraine condition. The staff were unaware of the reason behind the resident's constant use of sunglasses and did not know about the resident's history of migraines. The Director of Nurses acknowledged that a care plan should have been developed based on the pre-admission paperwork, which clearly mentioned the resident's migraine headaches.
Failure to Obtain Doctor's Orders for Resident Transfers
Penalty
Summary
The facility failed to adhere to professional standards of practice by not obtaining a doctor's order for the transfer of two residents. Resident #150, who was admitted with Huntington's disease, schizophrenia, and depression, was transferred to the hospital via ambulance without a doctor's order on April 4, 2024. The progress notes confirmed the transfer, but the doctor's orders for April 2024 did not include authorization for this action. During an interview, the Director of Nursing acknowledged that a doctor's order should have been obtained for the hospital transfer. Similarly, Resident #151, admitted with alcohol dependence, alcoholic cirrhosis of the liver, and psychosis, was discharged home without a doctor's order on May 11, 2024. The progress notes documented the discharge, but the doctor's orders for May 2024 lacked the necessary authorization. The Director of Nursing also confirmed that a doctor's order was expected for the discharge home.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD). Specifically, the facility did not conduct trauma assessments according to its policy and did not develop individualized comprehensive care plans for two residents with PTSD. Resident #146, admitted with diagnoses including PTSD, traumatic brain injury, and depression, had a care plan that aimed to avoid re-traumatization triggers. However, the care plan lacked specific details about the triggers, how the resident exhibits PTSD activation, and the necessary interventions to mitigate the impact during triggered events. Similarly, Resident #123, admitted with PTSD and moderate cognitive impairment, had a care plan that did not include personalized details about the traumatic events experienced or identified triggers to prevent re-traumatization. The social worker acknowledged that trauma is only assessed at admission unless a new traumatic event occurs during the resident's stay. The Director of Nurses confirmed that trauma care plans should be personalized with specific traumatic events and identified triggers, which was not done for Resident #123.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including focal traumatic brain injury, major depressive disorder, and epilepsy. The resident's Minimum Data Set (MDS) assessment indicated obvious or likely cavities or broken natural teeth, and the resident was cognitively intact. Despite a care conference note from January indicating the need for dental care due to discomfort from rotting teeth, and a physician's order for dental care as needed, the resident did not receive dental services. The resident reported dental pain and was using over-the-counter medication for relief, which was provided by a family member. Interviews with facility staff, including the Unit Manager and Director of Nurses (DON), revealed a lack of awareness and follow-through regarding the resident's dental pain and need for care. The DON stated that a dentist and dental hygienist visit the facility every few months, but was unaware of the resident's condition and the family's provision of Orajel for pain management. The facility's policy indicated that routine and emergency dental services should be available, yet the resident had not been seen by a dentist since admission, highlighting a failure in the facility's process to address the resident's dental needs in a timely manner.
Failure in Hand Hygiene Practices by Housekeeping Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were maintained by housekeeping staff on one of the four nursing units. The facility's policy on hand hygiene, revised on March 18, 2024, emphasizes the importance of hand hygiene as the primary means to prevent the spread of healthcare-associated infections. It requires all personnel to adhere to hand hygiene practices, including washing hands after contact with contaminated surfaces, after glove removal, and before entering another resident's environment. Additionally, the policy on personal protective equipment specifies that gloves should be used only once, discarded appropriately, and hands washed after glove removal. On June 26, 2024, a surveyor observed a housekeeper on the [NAME] Park Unit failing to follow these protocols. The housekeeper was seen wearing the same pair of gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. This was confirmed through interviews with the Housekeeping Manager, Infection Control Nurse, and Director of Nurses, all of whom stated that gloves should be removed before exiting a room, and hand hygiene should be performed before entering another room. The failure to adhere to these practices was identified as a deficiency in the facility's infection prevention and control program.
Inaccurate MDS Coding for Resident Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in January 2019 with diagnoses including traumatic subarachnoid hemorrhage and unspecified dementia, was incorrectly coded as using a trunk restraint. The MDS assessment indicated the resident used a trunk restraint less than daily, despite observations on multiple days showing the resident ambulating independently without any restraint. The resident's medical record lacked any physician's orders, care plans, or restraint assessments to support the use of a restraint. Interviews with the Unit Manager and the MDS Nurse confirmed that the coding was an error, as no residents in the facility used restraints.
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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