Care One At New Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bedford, Massachusetts.
- Location
- 221 Fitzgerald Drive, New Bedford, Massachusetts 02745
- CMS Provider Number
- 225650
- Inspections on file
- 21
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Care One At New Bedford during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. This resulted in insufficient monitoring and management of pressure ulcer risks.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not maintain a water management program specific to its building, as required for infection prevention and control. Documentation and diagrams referenced non-existent features and failed to identify hazardous areas for Legionella growth. Both the Director of Maintenance and the Administrator confirmed the program was not tailored to the facility and did not meet required criteria.
A resident with a right hand contracture and severe cognitive impairment did not have a comprehensive, individualized care plan addressing contracture or limited range of motion, despite documented needs and occupational therapy recommendations. Staff interviews confirmed the absence of a care plan for contracture management, and the DON acknowledged that one should have been developed.
Nursing staff did not ensure a resident, who was not approved for self-administration, took their prescribed medications as required. The resident was repeatedly found with multiple pills left in a medication cup, and staff admitted to not confirming ingestion before leaving the room, contrary to facility policy.
The facility did not maintain accurate and complete medical records for two residents. One resident's record lacked documentation of a historical diagnosis of schizoaffective disorder, despite staff having received this information from an outside provider. For another resident, the electronic medical record contained documents belonging to other individuals, which staff acknowledged were uploaded in error.
The facility failed to ensure accurate MDS assessments for two residents, with one resident incorrectly documented as using a restraint and another inaccurately recorded as receiving insulin when only a non-insulin injectable was administered. These inaccuracies were identified through interviews, record reviews, and direct observation.
The facility failed to secure controlled substances on Unit #1, where two medication carts had narcotic boxes that could be opened without a key. Despite the facility's policy requiring double-locked storage for such medications, staff interviews revealed awareness of the issue but no reporting. The DON was unaware of the problem, highlighting a breach in policy and federal regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage III pressure injury, as required by their policy to prevent the spread of MDROs. There was no signage or PPE available, and staff were unaware of the need for EBP. Interviews revealed a lack of communication and awareness among staff, including the Infection Preventionist and Director of Nurses, who acknowledged the oversight.
The facility failed to ensure that three residents were free from significant medication errors by administering Oxycodone outside the physician's prescribed pain parameters. Nursing staff did not notify the physician when administering the medication for lower pain scores, contrary to the orders.
The facility failed to act on the Consultant Pharmacist's recommendations during the monthly Medication Regimen Reviews (MRR) for a resident with chronic kidney disease and diabetes. The pharmacist did not identify irregularities in the administration of Oxycodone, leading to both dosages being prescribed for severe pain without a pain scale parameter.
The facility failed to accurately complete the MDS assessments for five residents, leading to multiple deficiencies. These included not indicating the use of formal assessment tools, antianxiety medications, diuretic medications, and antipsychotic medications, as well as inaccurately recording a discharge location. The discrepancies were confirmed through record reviews and staff interviews.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency indicates that residents were not consistently monitored or treated according to established protocols for pressure ulcer prevention and care, resulting in inadequate management of existing ulcers and insufficient prevention strategies for those at risk.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Facility-Specific Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding its water management program intended to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of the facility's Legionella Water Management Program policy and related documentation revealed that the written description of the building's water system and devices was not specific to the actual facility. The water system flow diagram included features, such as a trellis fountain and references to water supplied by the town, that did not exist in the facility. Additionally, the diagram did not clearly identify or classify hazardous areas or conditions that could encourage bacterial growth, such as stagnation, permissive temperatures, lack of disinfectant, or external hazards. Interviews with the Director of Maintenance and the Administrator confirmed that the water management program and assessment were not tailored to the facility and did not meet all required criteria. The Director of Maintenance acknowledged that the documentation was not specific to the facility and that the flow diagram failed to depict hazardous concerns. The Administrator also confirmed that the program should have been facility-specific and comprehensive, as required by policy.
Failure to Develop and Implement Comprehensive Care Plan for Contracture Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with a right hand contracture. Despite the resident's admission with diagnoses including right hand contracture, cerebral infarction, and muscle weakness, and documentation in the Minimum Data Set (MDS) assessment indicating severe cognitive impairment and upper extremity range of motion (ROM) impairment, there was no care plan addressing the contracture or limited ROM. Observations confirmed the presence of a contracture, and the occupational therapy (OT) discharge summary recommended specific interventions, such as a right resting hand splint and a left palm pillow, with a detailed wear schedule. However, these interventions were not reflected in the resident's care plan. Interviews with facility staff, including a CNA, nurse, unit manager, and DON, revealed a lack of awareness and documentation regarding a care plan for the resident's contractures. The CNA and nurse acknowledged the use of splints for the resident, but the nurse was unsure if a care plan existed. The unit manager confirmed that care plans are updated at least quarterly or with changes in condition, but upon review, found no care plan related to the resident's contractures or limited ROM. The DON also confirmed that such a care plan should have been in place.
Failure to Ensure Medication Administration According to Professional Standards
Penalty
Summary
Nursing staff failed to ensure that a resident was administered medications in accordance with professional standards of quality. The resident, who was cognitively intact and had not been assessed or approved to self-administer medications, was observed with multiple medications left in a cup on the overbed table on two separate occasions. The resident expressed confusion about when the medications were provided and indicated that they had not yet taken them. Review of the medical record confirmed that the resident had requested nursing staff to administer medications and had not been assessed for self-administration. Interviews with nursing staff and the unit manager confirmed that the resident was not on the list of those permitted to self-administer medications. Despite this, a nurse admitted to not waiting to ensure the resident had taken all medications before leaving the room. The facility's policy requires that only licensed personnel administer medications and that administration is completed in accordance with prescriber orders, including ensuring medications are actually taken. The failure to confirm medication ingestion resulted in the resident having unsupervised access to prescribed medications.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the medical record did not include full documentation of all diagnoses and psychiatric history, specifically omitting a historical diagnosis of schizoaffective disorder. Although the psychiatric nurse practitioner received records from the resident's community provider indicating a long history of schizoaffective disorder, this information was not entered into the facility's medical record or reflected in progress notes. The diagnosis was later added to the record following a hospitalization, but supporting documentation was not present in the medical record at the time of survey. Staff interviews confirmed that relevant documents were not filed appropriately and the medical record did not accurately reflect the resident's history or diagnoses. For another resident, the electronic medical record contained documents belonging to other residents, including an inpatient order and a provider progress note for two different individuals. Staff interviews revealed that these documents were incorrectly uploaded into the wrong resident's record by facility personnel. The Director of Nursing confirmed that these documents should have been filed in the correct residents' records and not in the affected resident's file.
Inaccurate MDS Assessments for Restraint and Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS inaccurately indicated the use of a physical restraint, specifically a bed rail, when in fact the resident had never had a restraint and the bed rails in use did not restrict movement. This was confirmed through interviews and direct observation, as well as a review of the resident's medical record and the facility's Matrix form. For another resident, the MDS assessments incorrectly documented the administration of insulin during two separate assessment periods. Review of the medical record showed that the resident had not received insulin during those times. The MDS Coordinator stated that the error occurred because she had mistakenly recorded the use of Victoza, a non-insulin injectable diabetes medication, as insulin. Upon review, the MDS Coordinator acknowledged that Victoza is not an insulin and that the MDS entries were inaccurate.
Failure to Secure Controlled Substances in Medication Carts
Penalty
Summary
The facility failed to ensure the secure storage of controlled substances on Unit #1, where two medication administration carts (A & B) were found to have narcotic boxes that could be opened without a key. This deficiency was identified during an observation by Surveyor #2, who noted that the narcotic boxes on both carts could be easily opened, making the controlled substances inside accessible. The facility's policy, last revised in February 2019, mandates that Schedule II-V medications and other drugs subject to abuse or diversion must be stored in a permanently affixed, double-locked compartment separate from other medications. Interviews with nursing staff revealed that Nurse #1 was aware of the issue with the narcotic box on cart A but had not reported it, while Nurse #2 acknowledged that the narcotic box on cart B sometimes opened without a key. The Director of Nurses (DON) was unaware of the malfunctioning locks and stated that the facility's expectation was for all narcotic boxes to be double-locked, with any issues reported immediately to the DON and maintenance. The failure to secure these medications properly represents a breach of the facility's policy and federal regulations regarding the handling and storage of controlled substances.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injury
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a worsening Stage III pressure injury, which is a necessary infection control measure to prevent the spread of Multi-Drug-Resistant Organisms (MDROs). The facility's policy requires EBP for residents with wounds, yet there was no documentation or physician's order indicating that EBP was needed for the resident. During the survey, it was observed that there was no signage or Personal Protective Equipment (PPE) available outside the resident's room, and staff were unaware of the need for EBP. Interviews with facility staff, including a Certified Nurse Aide, the Unit Manager, the Infection Preventionist, and the Director of Nurses, revealed a lack of awareness and communication regarding the resident's need for EBP. The Infection Preventionist and Director of Nurses acknowledged the oversight, indicating that the resident should have been placed on EBP due to the pressure injury. The deficiency highlights a breakdown in the facility's infection control procedures, as staff failed to initiate and maintain necessary precautions for the resident's condition.
Failure to Administer Pain Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, specifically in the administration of pain medication according to the physician's orders. Resident #73, who was cognitively intact, received Oxycodone for pain scores of 4 or below on multiple occasions, contrary to the physician's order that specified Oxycodone should only be administered for moderate to severe pain (pain scores of 5-10). Interviews with nursing staff revealed a lack of understanding of the pain scale parameters and a failure to notify the physician when administering Oxycodone outside the prescribed parameters. Resident #11, also cognitively intact, was administered Oxycodone 10 out of 21 times outside the physician's parameters, which specified that Oxycodone should only be given for severe pain (pain scores of 7-10). The nursing staff did not contact the physician for clarification or authorization before administering the medication outside the prescribed pain parameters. Interviews with the nursing staff and the Director of Nursing confirmed that the physician should have been notified in such cases, but there was no documentation to support that this was done. Resident #133, who had chronic kidney disease and diabetes with diabetic neuropathy, received Oxycodone 24 out of 34 times outside the physician's parameters. The physician's orders specified that Oxycodone should be administered for severe pain (pain scores of 8-10), but the medication was given for lower pain scores without notifying the physician. Interviews with the nursing staff and the resident confirmed that the medication was administered outside the prescribed parameters, and the Director of Nursing acknowledged that the physician should have been contacted in these instances but was not.
Failure to Act on Pharmacist's Recommendations for Pain Medication
Penalty
Summary
The facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one resident. Specifically, the pharmacist did not review and report irregularities related to the administration of Oxycodone for Resident #133, who was admitted with chronic kidney disease and diabetes with diabetic neuropathy. The resident's physician orders included two different dosages of Oxycodone for severe pain, but both orders lacked a pain scale parameter to distinguish between moderate and severe pain. This oversight was not identified in the MRR dated 5/17/24. Interviews with facility staff, including the MDS Nurse, Nurse #3, and the Director of Nursing (DON), confirmed that the orders should have included a pain range and that the two dosages should not have both been for severe pain. The resident reported being offered a choice between the two dosages and consistently chose the higher dose. The pharmacist acknowledged that he should have made a recommendation to distinguish between the two doses based on a pain scale but failed to do so during his review.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for five residents, leading to multiple deficiencies. For Resident #127, the facility did not indicate that a formal assessment instrument/tool was completed, despite the presence of a [NAME] Assessment in the resident's admission evaluation. Resident #11's MDS assessment failed to reflect the administration of an antianxiety medication, Clonazepam, which was prescribed and administered as per the physician's orders. Similarly, Resident #133's MDS assessment did not indicate the administration of a diuretic medication, Furosemide, which was also prescribed and administered according to the physician's orders. Resident #13's MDS assessment did not reflect the use of an antipsychotic medication, Nuplazid, due to a lack of awareness by the MDS nurse that Nuplazid is classified as an antipsychotic medication. Lastly, Resident #141's MDS assessment inaccurately indicated that the resident was discharged to an acute hospital, whereas the resident was actually discharged home with services, as documented in the care conference notes and nursing notes. These inaccuracies were identified through a combination of record reviews and staff interviews. The facility's policy on certifying the accuracy of the resident assessment, which requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion, was not adhered to in these cases. The MDS nurses involved acknowledged the discrepancies during interviews, confirming that the MDS assessments should have accurately reflected the residents' conditions and treatments during the observation period. The failure to accurately complete the MDS assessments for these residents indicates a lapse in the facility's adherence to its own policies and procedures for ensuring the accuracy of resident assessments.
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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