Care One At Newton
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Massachusetts.
- Location
- 2101 Washington Street, Newton, Massachusetts 02462
- CMS Provider Number
- 225268
- Inspections on file
- 29
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Care One At Newton during CMS and state inspections, most recent first.
A nurse used a personal cell phone to take photographs of three cognitively impaired, fully dependent residents and texted these images to a non-staff individual, in violation of facility policy on resident images and rights. The photos, later obtained through a BORN investigation and reviewed by the ADON, showed one resident standing fully clothed in a hallway, another sitting on the hallway floor in a johnny and brief, and another lying in bed in a johnny under bed linens. All three residents had documented dementia or related cognitive impairment on recent MDS assessments and were unable to be interviewed.
A resident with multiple complex medical conditions did not receive a physician-ordered antibiotic in a timely manner after developing a new area of redness and swelling. Although the medication was available on-site, the first dose was delayed by 14 hours due to a nursing supervisor's misunderstanding of administration timing, contrary to facility policy and physician expectations.
A resident with multiple complex medical conditions had abnormal blood test results indicating acute inflammation, but facility staff did not promptly notify the physician as required. The lack of timely communication and documentation led to a delay in appropriate medical intervention until the wound physician reviewed the results days later and arranged for hospital transfer.
Staff did not consistently follow infection control precautions for three residents requiring Enhanced Barrier, Contact, or Neutropenic Precautions. Certified Nurse Aides were observed providing care without the appropriate use of gowns and gloves, despite facility policies and posted signage indicating the required PPE for each resident's condition.
A resident with complex autoimmune conditions was prescribed Methotrexate weekly, but due to a transcription error, received the medication daily. The dispensing pharmacist overrode a DUR alert without verifying the order, and the pharmacy consultant failed to identify the excessive dosing during review. The resident developed acute toxicity, resulting in hospitalization for pancytopenia and related complications.
A resident with autoimmune and connective tissue disorders was administered Methotrexate daily instead of weekly due to a transcription error during medication reconciliation. Multiple staff, including nursing and medical providers, failed to identify the incorrect dosing frequency, resulting in the resident receiving toxic levels of the medication and requiring hospital transfer for treatment of Methotrexate toxicity.
A resident with complex autoimmune conditions had a medication order for Methotrexate incorrectly entered and signed for twice-daily administration instead of the intended weekly schedule. The physician did not catch the transcription error when signing, and a nurse practitioner documented reviewing all medications without recognizing the error, as only pertinent medications were actually reviewed and there was unfamiliarity with Methotrexate dosing.
Staff used a resident's private room for personal storage, documentation, and phone calls, despite facility policy prohibiting such actions. The resident, who was severely cognitively impaired and dependent on staff, was present during these incidents. Facility leadership confirmed that staff are not allowed to use resident rooms for personal purposes.
Staff failed to follow proper sanitation and food handling procedures during meal service, as multiple employees, including the Food Service Director and dietary aides, were observed handling food, utensils, and equipment with the same pair of gloves and without performing hand hygiene between tasks. Despite being aware of the facility's policy on handwashing and glove use, staff did not adhere to these practices, resulting in a deficiency related to safe food handling and cross-contamination prevention.
A resident with a court-appointed guardian and a court-approved antipsychotic treatment plan was administered Fluphenazine, a psychotropic medication, without obtaining the required legal consent from the court. The medication was not listed on the approved treatment plan, and facility staff confirmed that it was given prior to court authorization, contrary to facility policy.
A resident with a court-appointed guardian and a Roger's treatment plan for antipsychotic medications was given Fluphenazine, which was not included in the court-approved list of medications. Facility staff confirmed that the Roger's treatment plan should have been expanded in court before administering the new medication, but this was not done, resulting in the administration of an unapproved antipsychotic.
A resident with cognitive impairment and mobility needs was found using a wheelchair seatbelt without a physician's order, care plan intervention, or documented restraint assessment. Facility staff were unable to confirm if a restraint assessment had been completed, and the DON stated that such assessments should have been performed upon admission and throughout the resident's stay.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with major depression and psychosis, who had moderate cognitive impairment, was prescribed Risperidone and Trazodone without a care plan or physician order to monitor for side effects. Facility staff confirmed that monitoring for psychotropic medication side effects was not implemented as required.
Three residents did not receive care in accordance with physician orders and professional standards. One resident with dysphagia was given unthickened juice despite orders for thickened liquids. Another resident with severe cognitive impairment was repeatedly observed not wearing a prescribed Prevalon boot, with no documentation of refusal. A third resident was left with a medication cup at the bedside without an order or assessment for self-administration, contrary to facility policy. Staff interviews confirmed these actions were not consistent with required nursing practices.
A resident with severe cognitive impairment and a documented history of wandering was moved from a secured unit to a less secure area without consistent use of a wander guard, despite ongoing high elopement risk. The resident eloped and was missing for several hours before being found by police. Additionally, staff failed to respond appropriately to multiple open flame incidents in the kitchen, leaving a toaster unattended while it was on fire and not following fire safety protocols.
A dietary aide with an uncovered laceration and stitches on his finger was observed performing food service tasks without proper hand hygiene, including handling food and clean dishes after touching potentially contaminated surfaces. The aide's injury was not properly reported or managed according to facility policy, and key staff were unaware of the extent of the injury, resulting in a breakdown of infection prevention and control procedures.
A resident with diabetes, PVD, and neuropathy did not receive timely podiatry foot care despite repeated requests from their health care agent and NP. Multiple recommendations to add the resident to the podiatry list were not acted upon, and staff were unaware of the need for referral. The resident's toenails were found to be severely overgrown and in poor condition when finally seen by a podiatrist.
A resident with complex medical needs, including metastatic cancer and multiple hospital readmissions, did not have their comprehensive care plan reviewed or revised after a scheduled quarterly MDS assessment or following readmissions, contrary to facility policy. Staff interviews confirmed a lack of awareness regarding the missed care plan updates.
A resident with a known shellfish allergy was served a meal containing shrimp, leading to a severe allergic reaction. Despite facility policies requiring verification of dietary restrictions, the meal was not checked against the resident's allergies. The resident experienced anaphylaxis and required emergency medical intervention.
A resident with a known shellfish allergy was served a meal containing shrimp, leading to anaphylaxis and hospitalization. The dietary aide failed to communicate the allergy to the cook, and the nurse did not verify the diet slip for allergies before serving the meal. This incident highlights a breakdown in the facility's procedures for ensuring dietary restrictions are met.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to protocols for PPE and hand hygiene. A resident on contact precautions for C. difficile was visited by staff without PPE, and hand hygiene was not performed after handling contaminated items. Observations included a nurse administering medications without PPE and handling contaminated items with bare hands. Facility leadership confirmed expectations for PPE and hand hygiene, which were not met.
A facility failed to renew a resident's guardianship necessary for administering antipsychotic medications. The resident, with intact cognition and multiple mental health diagnoses, was taking high-risk medications but lacked a current court-approved treatment plan. The facility's policy requires annual review of advance directives, but the renewal process was delayed, leading to an expired treatment plan. The Social Worker admitted the lapse, and the resident's legal guardian reported difficulties in obtaining needed information from the facility.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in care. One resident, an elopement risk, was observed without a wander guard despite severe cognitive impairment and a history of wandering. Another resident, at risk for pressure ulcers, was not offloading heels as ordered and was not wearing eyeglasses as prescribed. Staff interviews confirmed the lack of adherence to care plans and physician orders.
A resident with aspiration precautions was left unsupervised during meals, despite requiring one-to-one assistance. Observations showed the resident attempting to eat alone, and interviews with staff confirmed the need for supervision. The care plan was not updated to reflect the resident's dietary needs and supervision requirements.
A resident with limited English proficiency, speaking Cantonese, did not receive necessary communication services in an LTC facility. Despite a care plan indicating the need for translation services, staff failed to use available resources, resulting in ineffective communication. Observations showed CNAs interacting with the resident without speaking or using interpreters, and interviews confirmed a lack of adherence to the communication policy.
A resident in an LTC facility did not receive Total Parenteral Nutrition (TPN) as ordered by the physician, leading to a deficiency. The TPN was administered at an incorrect rate, and the total volume was insufficient. Nursing staff failed to adhere to the physician's orders, and the dietitian's plan to taper the TPN was not reflected in updated orders. This oversight resulted in improper administration of TPN.
A facility failed to assess a resident's history of trauma and develop a care plan with specific triggers and interventions for PTSD. Despite having a policy for trauma-informed care, the facility lacked an assessment tool, and the Social Service Admission Assessment was not completed. The resident, with diagnoses of PTSD and bipolar disorder, had a care plan that did not address PTSD or include specific interventions. Interviews with staff revealed the care plan was incomplete and inappropriate.
The facility did not ensure medication carts were locked on one nursing unit, as required by policy. A medication cart was observed unlocked and unsupervised on two occasions. Interviews with staff confirmed that carts should be locked if a nurse is not present.
A facility failed to ensure correct physician's orders for oxygen administration for a resident with cancer and diabetes. The resident was observed using four liters of oxygen, while the orders indicated three liters. The respiratory therapist confirmed the need for four liters following a hospitalization, but the orders were not updated accordingly.
Unauthorized Resident Photographs Texted to Non-Staff Person
Penalty
Summary
The deficiency involves the facility’s failure to protect three cognitively impaired residents’ rights to respect, dignity, and privacy when a nurse took and transmitted their photographs without knowledge or consent. Facility policy titled “Videotaping, Photographing and Other Images of Resident,” revised February 2021, stated that transmitting unauthorized images of any resident through email, internet, or social media is considered a violation of resident rights. Despite this policy, Nurse #1 used a personal cell phone on two dates to photograph residents and send those images via text message to a non-staff individual. According to the facility’s internal investigation and information received from the Board of Registration of Nursing (BORN), Nurse #1 initially denied taking and sending the photographs but later admitted to doing so. Photographs obtained from a cell phone text thread provided by BORN showed that Nurse #1 had sent images of three residents to a non-staff person. The Assistant Director of Nursing (ADON), after reviewing the photographs on Nurse #1’s phone, was able to identify the individuals in the images as the three sampled residents. The residents involved were all cognitively impaired and dependent on staff for care. One resident, admitted in June 2025 with diagnoses including dementia, had a quarterly MDS dated 12/05/25 indicating severe cognitive impairment and dependence on staff for care needs. A second resident, also admitted in June 2025 with traumatic brain injury and vascular dementia, had a quarterly MDS dated 12/05/25 showing moderate cognitive impairment and dependence on staff. The third resident, admitted in June 2025 with vascular dementia and failure to thrive, had a quarterly MDS dated 10/31/25 indicating severe cognitive impairment and dependence on staff. The ADON described the photographs as showing one resident standing fully clothed in a hallway, another sitting on the floor in a hallway wearing a johnny and brief, and another lying in bed wearing a johnny and covered with bed linens. All three residents were non-interviewable due to cognitive impairment.
Delayed Administration of Physician-Ordered Antibiotic
Penalty
Summary
Facility staff failed to administer a physician-ordered antibiotic to a medically compromised resident in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis following a cerebral infarction, developed a reddened and swollen genital area that was tender to touch. The on-call Nurse Practitioner was notified and ordered Levofloxacin 500 mg daily for 10 days, with instructions for the resident to be seen the following day. Although the antibiotic was available in the facility's emergency medical supply, the first dose was not given until 14 hours after the order was received. Review of documentation and interviews revealed that the Nursing Supervisor on duty entered the order into the Medication Administration Record (MAR) but scheduled the first dose for the following morning, believing that was the correct procedure. Both the physician and the Director of Nursing later confirmed that the first dose should have been administered the evening the order was received. Facility policy required all administered medications to be documented in the resident's medical record, and the delay in administration was not consistent with this policy.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
Facility staff failed to ensure that abnormal laboratory results for a medically compromised resident were reported to the physician in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis, had physician orders for blood tests including Sedimentation Rate (ESR), C Reactive Protein (CRP), and a Basic Metabolic Panel. The laboratory results, which showed significantly elevated ESR and CRP levels indicating acute inflammation, were received by the facility but there was no documentation that these abnormal results were communicated to the resident's physician. Subsequent documentation showed that the resident developed cellulitis of the genital area and a new autoimmune disease-induced wound. The wound physician, upon reviewing the lab results days later, determined that the resident required transfer to the hospital for further evaluation and intravenous antibiotics. Interviews with facility staff and physicians confirmed that the abnormal lab results were not reported to the primary care provider or wound physician in a timely manner, and there was no documentation of provider notification in the medical record as required by facility policy.
Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to implement and follow infection control precautions for three residents who required specific infection prevention measures. Facility policy required the use of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, including the use of gloves and gowns during high-contact care activities. One resident with an indwelling urinary catheter and a sacral pressure injury had a care plan intervention for EBP, but a Certified Nurse Aide (CNA) was observed providing bed mobility and adjusting linens without wearing a gown, stating she believed gowns were only necessary during wound care. Another resident with MRSA and an indwelling urinary catheter was under Contact Precautions per physician orders and facility policy, which required staff to wear gloves and gowns upon entering the room. However, a CNA was observed assisting the resident with eating without wearing a gown and stated she was unaware of the specific precautions required for the resident. The signage indicating the need for Contact Precautions was present outside the room. A third resident, who had pancytopenia, a colostomy, and endocarditis, required Neutropenic Precautions, including hand hygiene, gloves, and gowns before entering the room. A CNA entered the resident's room without gloves or a gown, later returning to apply gloves but not a gown, and admitted to forgetting the required PPE. The Director of Nurses confirmed that each resident was on different infection control precautions and expected staff to follow the posted signage and wear the appropriate PPE.
Failure to Identify and Report Methotrexate Dosing Error
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review, including a review of the medical chart, and failed to identify and report a medication prescribed and administered at an excessive frequency. Specifically, a resident with diagnoses of Antiphospholipid Syndrome and CREST syndrome was admitted with a hospital discharge order for Methotrexate 25 mg to be given once weekly. However, due to a transcription error by a nurse, the medication was entered into the electronic medical record to be administered daily instead of weekly. The error was not detected by the dispensing pharmacist, who overrode a Drug Utilization Review (DUR) alert without verifying the order with the facility, nor by the pharmacy consultant during the interim medication regimen review. As a result, the resident received Methotrexate at a daily dose for several days, far exceeding the recommended frequency. The facility's policy required the pharmacist to identify, evaluate, and address medication-related issues, but this process failed at multiple points, including order entry, pharmacy review, and consultant pharmacist oversight. The resident subsequently experienced an acute decline in condition, including respiratory distress, decreased oxygen levels, loose bowel movements, and decreased intake, leading to hospital transfer. Hospital records indicated the resident developed pancytopenia likely due to chronic Methotrexate toxicity, with toxic drug levels confirmed. The failure to identify and report the medication error in a timely manner directly contributed to the resident's adverse outcome.
Significant Medication Error Due to Incorrect Methotrexate Transcription
Penalty
Summary
A significant medication error occurred when a resident with complex medical conditions, including Antiphospholipid Syndrome and CREST syndrome, was admitted to the facility. The resident's hospital discharge summary specified that Methotrexate, an oral chemotherapy agent with a black box warning, was to be administered as 10 tablets (25 mg) once weekly, divided into morning and evening doses. However, upon admission, nursing staff inaccurately transcribed the order into the electronic medical record, resulting in the medication being scheduled and administered as 5 tablets twice daily, every day, rather than once weekly as intended. The error went undetected by multiple staff members, including the admitting nurse, the reviewing physician, and the nurse practitioner, all of whom either entered or reviewed the orders without recognizing the incorrect frequency. The nurse who entered the order admitted unfamiliarity with Methotrexate dosing, and the nurse practitioner stated that Methotrexate was managed by specialists and did not question the listed frequency. As a result, the resident received excessive doses of Methotrexate over several consecutive days. Following the administration of Methotrexate at the incorrect frequency, the resident experienced a decline in condition, including acute respiratory distress, decreased oxygen levels, gastrointestinal symptoms, and reduced intake. The resident was transferred to the hospital, where laboratory findings confirmed toxic levels of Methotrexate and pancytopenia, consistent with chronic Methotrexate toxicity. The facility's Director of Nursing and Medical Director acknowledged that the medication reconciliation and transcription process was not performed in accordance with facility protocol, leading to the significant medication error.
Incomplete and Inaccurate Medical Record Due to Medication Order Error
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record in two significant ways. First, a physician electronically signed a medication order for Methotrexate to be administered twice daily, rather than the correct frequency of once weekly as indicated in the hospital discharge summary. The physician stated that he reviewed the discharge summary and intended to continue all listed medications, but due to the high volume of electronic orders received, he did not identify the transcription error made by nursing staff when entering the order. As a result, the incorrect order was signed and became part of the resident's medical record. Additionally, a nurse practitioner documented in progress notes that all of the resident's medications were reviewed at each visit, including the erroneous Methotrexate order. However, the nurse practitioner later stated that only medications pertinent to the visit were actually reviewed, and that he was not familiar enough with Methotrexate's recommended administration frequency to question the order as written. The medical director and director of nursing both confirmed their expectations that providers should identify such errors and that all medical record entries must be complete and accurate. The resident involved had diagnoses of Antiphospholipid Syndrome and CREST syndrome at the time of the incident.
Staff Use of Resident Room for Personal Storage and Activities
Penalty
Summary
Staff failed to respect a resident's right to a dignified existence by using the resident's private room for personal storage and documentation. Multiple observations showed staff charging personal devices, storing personal items such as a white plastic bag and shoes, and making personal phone calls in the resident's room. Staff were also observed documenting on facility iPads while seated in the resident's room, sometimes with their eyes closed or speaking aloud on the phone. These actions occurred while the resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was present in the room, often asleep or nonresponsive. Interviews with facility leadership confirmed that staff are not permitted to store personal belongings, make personal calls, or document in resident rooms, as these spaces are considered private. Despite these policies, staff continued to use the resident's room for personal purposes, as evidenced by repeated observations over several days. The facility's own policy emphasized respect for residents' private space and property at all times, which was not upheld in this instance.
Failure to Follow Proper Sanitation and Food Handling During Meal Service
Penalty
Summary
Staff in the facility's kitchen failed to follow proper sanitation and food handling procedures during breakfast meal service. Multiple staff members, including the Food Service Director and several dietary aides, were observed wearing gloves while handling various items such as food, utensils, trays, and food carts, but did not change gloves or perform hand hygiene between tasks. For example, the Food Service Director used the same pair of gloves to touch potentially contaminated surfaces like steam table lids and food cart handles, and then handled ready-to-eat foods and serving utensils without changing gloves or washing hands. Similar practices were observed among dietary aides, who also failed to perform hand hygiene after removing gloves and continued to handle food and clean dishes with potentially contaminated hands or gloves. Interviews with staff confirmed their awareness of the facility's policy requiring handwashing before and after glove use, and the need to change gloves and wash hands after touching non-food items. Despite this knowledge, staff did not adhere to these procedures during the observed meal service. The facility's policy emphasizes the importance of preventing cross-contamination and following safe food handling practices, but these were not followed as observed by surveyors during the breakfast meal service.
Psychotropic Medication Administered Without Court-Approved Consent
Penalty
Summary
The facility failed to obtain legal informed consent from the court prior to administering a psychotropic medication, Fluphenazine, to a resident with a court-appointed guardian and an existing court-approved treatment plan. The resident, who was admitted with schizoaffective disorder and demonstrated intact cognition, was administered Fluphenazine over several days as ordered by the physician. However, a review of the Roger's treatment plan, which authorizes specific antipsychotic medications for the resident, did not include Fluphenazine among the approved or alternative medications. Interviews with facility staff and the court-appointed Roger's Monitor confirmed that Fluphenazine was given without prior court authorization, as required by the treatment plan and facility policy. The facility's policy mandates that legal informed consent must be obtained before initiating or changing psychotropic medications, including reviewing non-pharmacological alternatives and potential risks with the resident or their representative. The failure to secure court approval for Fluphenazine administration constituted a breach of this policy and legal requirements.
Antipsychotic Medication Administered Without Court Approval
Penalty
Summary
The facility failed to ensure that an advance directive, specifically a court-approved Roger's treatment plan, was properly expanded before administering a new antipsychotic medication to a resident. The resident, who had a diagnosis of schizoaffective disorder and was cognitively intact, had a court-appointed guardian and a Roger's treatment plan in place that outlined which antipsychotic medications were authorized for use. However, Fluphenazine, the antipsychotic medication administered to the resident over several days, was not included in the list of approved or alternative medications in the current Roger's treatment plan. Interviews with facility staff, including the Regional Social Worker and the Director of Nurses, confirmed that the medication should not have been administered without first obtaining court approval to expand the Roger's treatment plan. The court-appointed Roger's monitor was also unaware that court approval was required for the new medication. This sequence of events resulted in the administration of an antipsychotic medication without the necessary legal authorization as required by the resident's advance directive and court order.
Failure to Assess and Document Wheelchair Seatbelt Use as Potential Restraint
Penalty
Summary
A deficiency occurred when a resident with dementia, traumatic brain injury, legal blindness, and unsteadiness was found using a wheelchair with a seatbelt that had not been properly assessed as a potential restraint. The facility's policy required a pre-restraining assessment and ongoing review to determine the need for restraints and to consider less restrictive interventions. However, there was no documentation of a physician's order for the seatbelt, no mention of the seatbelt in the resident's care plans, and no completed restraint assessment in the medical record. Staff interviews revealed uncertainty regarding whether a restraint assessment had ever been completed for the seatbelt, and the DON acknowledged that a formal assessment should have been done upon admission and periodically thereafter. The resident was unable to explain the purpose or duration of the seatbelt use, and staff were unclear about the requirements for restraint assessment, leading to a failure to ensure the resident was free from unnecessary restraints as required by facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to develop and implement a care plan for monitoring the effects of psychotropic medications for one resident with diagnoses of major depression and unspecified psychosis. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 8 out of 15, was prescribed Risperidone and Trazodone. The physician orders did not include instructions to monitor for side effects of these psychotropic medications, and a corresponding care plan was not present in the resident's records. Interviews with facility staff, including a nurse, unit manager, assistant director of nursing, and director of nursing, confirmed that there was no care plan or physician order in place to monitor for potential side effects of the psychotropic medications. The staff acknowledged that such a care plan and monitoring order should have been developed for any resident receiving psychotropic medications, but this was not done for the resident in question.
Failure to Implement Physician Orders and Adhere to Professional Standards
Penalty
Summary
The facility failed to meet professional standards of quality for three residents by not implementing physician's orders and not adhering to established nursing practices. For one resident with dysphagia, the nurse administered aspirin dissolved in applesauce and followed it with unthickened apple juice, despite orders specifying that only moderately thick liquids should be given. The speech therapist and Director of Nursing confirmed that the resident should not have received thin liquids, and the nurse admitted to not thickening the juice as required. Another resident with peripheral vascular disease and severe cognitive impairment had a physician's order for a Prevalon boot to be worn on the right lower extremity at all times as tolerated. Multiple observations showed the resident was not wearing the boot during various activities and times of day, even though the treatment administration record indicated otherwise. Staff interviews revealed that the resident did not refuse care, and there was no documentation of refusal or behavioral issues. The Assistant Director of Nursing and Director of Nursing both stated that physician's orders should be followed and verified by staff. A third resident, who was cognitively intact but required supervision for daily activities, was found with a medication cup containing partially disintegrated pills left at the bedside. The nurse had left the medication with the resident while the resident was getting dressed, without a physician's order or care plan for self-administration. Facility policy and staff interviews confirmed that medications should not be left with residents unless there is a specific order and assessment for self-administration. The Director of Nursing reiterated that nurses are to stay with residents to ensure medications are taken as ordered.
Failure to Prevent Resident Elopement and Inadequate Fire Safety Response
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. One resident with severe cognitive impairment and a history of wandering and elopement was moved from a secured, code-locked unit to a less secure unit. Despite documented high risk for elopement and repeated nursing notes indicating increased wandering behaviors, the resident was not consistently provided with a wander guard as ordered. The Treatment Administration Record showed that the wander guard was not in place for several days prior to the resident's elopement, and there was no documentation that the clinical team was notified of the missing device. The resident subsequently eloped from the facility and was missing for four hours before being found by police. Interviews with facility staff, including the Unit Manager, Assistant DON, and DON, revealed a lack of awareness regarding the resident's increased elopement risk and the absence of the wander guard. The decision to move the resident was based on the perception that the resident was doing better and needed more activity participation, despite ongoing documentation of high elopement risk. The staff failed to communicate changes in the resident's behavior and the missing wander guard, resulting in inadequate supervision and a failure to implement necessary interventions. Additionally, the facility did not respond appropriately to an open flame fire in the kitchen during breakfast service. Surveyors observed multiple instances where a conveyor toaster caught fire, producing open flames and smoke, while dietary staff left the appliance unattended. Staff attempted to remove burning food with metal tongs without unplugging the toaster and failed to notify supervisors or follow fire safety protocols. Items were also improperly stored on top of the hot toaster, increasing the risk of fire. Interviews with dietary staff and the Food Service Director confirmed a lack of adherence to fire safety procedures and inadequate response to the fire incidents.
Failure to Enforce Infection Control Policies for Staff with Open Wounds
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a dietary aide working in the kitchen with an uncovered laceration and stitches on his left index finger. The aide was observed performing food service tasks, such as moving food carts, handling clean serving plates, and picking up food items, while wearing a glove on the injured hand. The glove was used to touch potentially contaminated surfaces and then clean items without hand hygiene being performed between tasks. The aide also removed and replaced gloves without washing his hands and at times handled food and food packaging with his bare, injured hand. The stitches on his finger were exposed and not covered, contrary to facility policy and standard infection control practices. Interviews revealed that the dietary aide had informed the Food Service Director (FSD) about his injury, but the FSD was unaware of the extent of the injury and did not report it to other relevant staff. The Human Resource Director and Director of Nursing (DON) were not notified of the injury, and both stated that staff with open wounds or stitches should not be working without proper clearance and the ability to perform hand hygiene. The administrator confirmed that the staff member should not have been working until cleared and emphasized the requirement for staff to be able to wash their hands appropriately. The failure to communicate and enforce occupational health policies resulted in the aide working with an open wound, unable to perform necessary hand hygiene, and potentially compromising infection control in the facility.
Failure to Provide Timely Podiatry Foot Care for Diabetic Resident
Penalty
Summary
A resident with diabetes mellitus, peripheral vascular disease, diabetic neuropathy, and a history of right below-knee amputation was not provided timely foot care, specifically toenail care, after multiple requests were made by the resident’s health care agent and palliative care nurse practitioner. Despite documented recommendations from the nurse practitioner in the resident’s medical record over several months to add the resident to the facility’s podiatry list, there was no evidence that the resident was referred to or seen by the podiatrist during scheduled visits in the facility. The facility’s own policy required that residents with medical conditions associated with foot complications be referred to qualified professionals and assisted with appointments as needed. Interviews with facility staff, including the ADON and DON, revealed a lack of awareness regarding the repeated recommendations for podiatry care for this resident. The resident’s consent for a podiatry consult was not obtained until several months after the initial requests, and the first documented podiatry visit and treatment occurred only after a significant delay. At the time of the podiatry visit, the resident’s toenails were found to be elongated, dystrophic, discolored, mycotic, thick, yellow, lytic, and required debridement, indicating prolonged lack of appropriate foot care.
Failure to Review and Revise Comprehensive Care Plan After MDS Assessment and Readmissions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised following the completion of a scheduled Quarterly Minimum Data Set (MDS) assessment, as required by facility policy. The policy states that the Interdisciplinary Team (IDT), in conjunction with the resident and their family or legal representative, must review and revise the care plan at least quarterly, upon significant changes in condition, when desired outcomes are not met, and upon readmission. Despite the completion of a quarterly MDS assessment and multiple hospital readmissions, there was no documentation that the care plan had been reviewed or updated for this resident during a six-month stay. The resident involved had complex medical needs, including metastatic anaplastic thyroid cancer requiring a tracheostomy and gastrostomy tube, chronic pulmonary embolism, and deep vein thrombosis. Interviews with MDS nurses and the DON revealed that they were unaware the care plan had not been reviewed or revised as required. The expectation, as stated by staff, was that care plans should be reviewed and revised after each comprehensive MDS and upon readmission, but this did not occur for the resident in question.
Failure to Prevent Allergic Reaction Due to Shellfish Exposure
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a known shellfish allergy, leading to a severe allergic reaction. The resident, who was admitted in September 2024, had documented allergies to shellfish, among other allergens. Despite this, on September 12, 2024, the resident was served a meal containing shrimp, which they consumed, resulting in an anaphylactic reaction. The resident experienced symptoms such as shortness of breath, puffy watery eyes, and a flushed appearance, eventually developing stridor, a high-pitched respiratory sound indicating a narrowed airway. The facility's policies on food allergies and tray identification were not adequately followed. The policies required that residents with severe food allergies have their meals specially prepared to avoid cross-contamination and that nursing staff check each food tray for the correct diet before serving. However, the nurse responsible for checking the meal tray did not verify the resident's diet slip for allergies, leading to the resident being served a meal with shrimp. The dietary substitution list indicated that seafood was substituted for the planned meal, but this was not communicated or checked against the resident's known allergies. Interviews with staff revealed lapses in the adherence to protocols. The nurse who checked the meal tray did not recall seeing any seafood and admitted to not checking the diet slip for allergies. The CNA who served the meal also did not verify the contents against the resident's dietary restrictions. The Director of Nursing confirmed that the facility was aware of the resident's shellfish allergy upon admission, but the error occurred due to a failure in the communication and verification process between the kitchen and nursing staff.
Removal Plan
- Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary).
- The Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl.
- The Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physicians' and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present.
- The Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy.
- All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine.
- The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed.
- The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month.
- The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved.
- The Director of Nurses and/or designee are responsible for overall compliance.
Failure to Accommodate Resident's Shellfish Allergy
Penalty
Summary
The facility failed to ensure that meals prepared and served to a resident with a known shellfish allergy accommodated this dietary restriction. On September 12, 2024, dietary staff mistakenly included a meal containing shrimp on the resident's dinner tray. This oversight led to the resident experiencing anaphylaxis, a severe allergic reaction, which required emergency medical intervention and hospitalization. The facility's policies on food and nutrition services and tray identification were not adequately followed. The dietary aide responsible for calling out diet orders to the cook did not communicate the resident's shellfish allergy, resulting in the incorrect meal being prepared and served. Additionally, the nurse who checked the meal tray before serving it to the resident failed to verify the diet slip for allergies, contributing to the resident's exposure to shellfish. The resident, who had a history of allergies to shellfish, iodine, Zoloft, cat/dog dander, and pollen extract, suffered significant respiratory distress after consuming the shrimp. Despite the facility's procedures requiring multiple checks to prevent such errors, the breakdown in communication and verification processes led to the resident's hospitalization for anaphylaxis.
Removal Plan
- Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary).
- The Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl.
- The Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physician and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present.
- The Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy.
- All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine.
- The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed.
- The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month.
- The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved.
- The Director of Nurses and/or designee are responsible for overall compliance.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to established protocols for personal protective equipment (PPE) and hand hygiene. Specifically, staff did not utilize appropriate PPE before entering the room of a resident on contact precautions for Clostridium difficile (C. difficile), a highly contagious bacteria. The surveyor observed a staff member entering the resident's room without PPE, despite the presence of a precaution bin filled with PPE and a contact precaution sign outside the room. Further observations revealed that staff did not perform hand hygiene after exiting the resident's room, which was on contact precautions for C. difficile. A staff member was seen assisting the resident with hand cleaning, then contaminating a plastic bag and the door handle without performing hand hygiene. Additionally, during a medication pass, a nurse administered medications to the resident without wearing PPE and handled contaminated items with bare hands, further spreading potential pathogens. The facility's infection control policies, including those specific to C. difficile and hand hygiene, were not followed by staff, as evidenced by multiple instances of non-compliance. The Director of Case Management and Nurse #7 were both observed entering the resident's room without PPE and handling personal and medical items without sanitizing them or performing hand hygiene. Interviews with facility leadership, including the Director of Nurses, Regional Nurse, Infection Control Nurse, and Medical Director, confirmed that staff were expected to follow PPE and hand hygiene protocols, which were not adhered to in these instances.
Failure to Renew Guardianship for Antipsychotic Medication
Penalty
Summary
The facility failed to formulate an advance directive for a resident, specifically neglecting to initiate the court process to renew an expired guardianship necessary for the administration of antipsychotic medications. The resident, who was admitted with diagnoses including suicidal ideations, major depressive disorder, and schizoaffective disorder, had a legal guardian and was taking high-risk medications. Despite having intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, the facility did not have a current treatment plan approved by the court for the use of antipsychotic medications. The facility's policy on advance directives requires that such directives be reviewed annually and that any changes be documented and communicated to the care team. However, the resident's treatment plan had expired, and there was no evidence of a renewed plan in the medical record. Interviews with facility staff revealed that the process for renewing the treatment plan had not been initiated in a timely manner, leading to the expiration of the necessary court approval for the resident's medication regimen. The Social Worker acknowledged the lapse, stating that the renewal process had only been started on the day of the survey. The resident's legal guardian expressed frustration over the delay, citing difficulties in obtaining necessary information from the facility, which hindered the submission of paperwork to the court. This deficiency highlights a breakdown in the facility's process for managing and renewing critical treatment plans for residents requiring antipsychotic medications.
Failure to Implement Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to implement a person-centered care plan for two residents, leading to deficiencies in their care. Resident #82, who was assessed as an elopement risk due to severe cognitive impairment and a history of wandering, was observed multiple times without a wander guard on their ankle. Despite the care plan indicating the need for a wander guard, staff interviews revealed a lack of awareness and documentation regarding the resident's removal of the device. Resident #31, with severe cognitive impairment and at risk for pressure ulcers, was observed lying in bed with heels directly on the mattress, contrary to a physician's order to offload heels for wound healing. Additionally, the resident was not wearing eyeglasses as prescribed, despite having adequate vision with corrective lenses. Interviews with staff confirmed the failure to follow physician orders for both heel offloading and eyeglass use. The deficiencies highlight a lack of adherence to care plans and physician orders, resulting in inadequate care for the residents. The facility's failure to ensure the implementation of necessary interventions for these residents was evident through observations and staff interviews, indicating a gap in communication and documentation processes.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who required assistance due to aspiration precautions. The resident, admitted with diagnoses including acute respiratory failure, pneumonia, and metabolic encephalopathy, was observed on multiple occasions attempting to eat meals unsupervised in their room. Despite the resident's care plan indicating the need for one-to-one assistance with eating, no staff were present during these meal times. Interviews with facility staff, including a CNA, Unit Manager, Speech Therapist, and the Director of Nursing, confirmed that the resident required supervision during meals due to aspiration precautions. The speech therapy evaluation had downgraded the resident's diet to pureed with thin liquids, emphasizing the need for supervision. However, the care plan was not updated to reflect these requirements, leading to the resident being left unsupervised during meals, contrary to the facility's policy and the expectations of the staff.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility staff failed to provide necessary communication services for a resident with limited English proficiency, specifically Cantonese. The resident was admitted with several medical conditions, including acute respiratory failure and pneumonia, and had a documented language barrier. Despite the facility's policy to ensure meaningful communication with residents who have limited English proficiency, the resident's primary language was not indicated on the active ADL flow sheet or the laminated care sign in the resident's room. Observations revealed that staff members, including CNAs, did not effectively communicate with the resident. CNAs were seen entering the resident's room and performing tasks without speaking to the resident or using translation services. Interviews with staff members indicated a lack of awareness or utilization of available interpreter services, despite the resident's care plan specifying the need for such services. Interviews with the Unit Manager, DON, and Regional Nurse confirmed that the resident required translation services and that the care plan should have been updated to reflect the resident's language needs. The staff was expected to use translation services and communication aids, such as a communication binder, to assist in communicating with the resident. However, these measures were not implemented, leading to a deficiency in providing necessary communication services to the resident.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to administer Total Parenteral Nutrition (TPN) as ordered by the physician for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including peritoneal abscess and adult failure to thrive, was supposed to receive a specific TPN regimen. However, observations revealed discrepancies in the infusion rate and total volume of TPN administered. The resident's TPN was observed running at an incorrect rate of 90 mls per hour, contrary to the physician's order, which specified different rates for different times of the day. Interviews with nursing staff indicated a lack of adherence to the physician's orders. Nurse #2, who worked the evening shift, admitted to following the instructions on the TPN bag rather than the physician's orders. Nurse #3, who worked the overnight shift, did not check the TPN infusion. The unit manager confirmed that the TPN should have been administered as ordered and that every shift nurse should verify the infusion rate. The TPN machine was noted to have completed the infusion earlier than scheduled, further indicating a deviation from the prescribed regimen. The dietitian's notes showed a plan to taper the TPN before discharge, with a gradual decrease in calories. However, the physician's orders had not been updated to reflect these changes since mid-June. The dietitian was unaware that the orders had not been modified and emphasized the importance of ensuring that the TPN solution bags match the physician's orders upon arrival at the facility. This oversight in updating the orders and verifying the infusion rates contributed to the deficiency in the resident's care.
Failure to Assess and Care Plan for PTSD
Penalty
Summary
The facility failed to assess a history of trauma and develop a care plan with resident-specific triggers and interventions for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma Informed Care and Culturally Competent Care, revised in August 2022, outlines the need for universal screening of residents for possible exposure to traumatic events and the development of individualized care plans. However, the facility did not have an assessment tool to evaluate residents for a history of trauma, and the Social Service Admission Assessment was not completed for the resident in question. The resident, admitted in January 2023, had diagnoses including PTSD and bipolar disorder, and was assessed to have severely impaired cognition. Despite this, the care plan did not include an assessment of PTSD or any resident-specific triggers or interventions. Interviews with the facility's Social Worker, Director of Nursing, and Regional Nurse revealed that the facility lacked a PTSD assessment tool and that the care plan for the resident was incomplete and inappropriate. The Social Worker acknowledged that the care plan should have included details about the trauma and specific triggers, but this information was not obtained or documented.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked on one of four nursing units, as required by their policy on Medication Labeling and Storage. The policy mandates that compartments containing medications and biologicals must be locked when not in use, and carts used to transport these items should not be left unattended if open. On two separate occasions, the surveyor observed the medication cart on the right side of the [NAME] Unit unlocked and unsupervised. Interviews with a nurse, the Unit Manager, and the Director of Nurses confirmed that the expectation is for medication carts to be locked at all times if the nurse is not present at the cart.
Incorrect Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that the physician's orders for oxygen were written correctly for a resident. The resident, admitted in February 2020 with diagnoses including cancer and diabetes, was observed by a surveyor on multiple occasions wearing oxygen set at four liters per minute (LPM), despite the physician's orders indicating three LPM via aerosolized trach mask. The resident was cognitively intact and required assistance with transfers and bathing. The respiratory therapist's notes from June to July 2024 indicated the resident was on four liters of oxygen and unable to be weaned down. During an interview, the respiratory therapist confirmed that the resident required four liters of oxygen following a hospitalization in May 2024, and acknowledged that the physician's orders should reflect this requirement.
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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