Care One At Northampton
Inspection history, citations, penalties and survey trends for this long-term care facility in Northampton, Massachusetts.
- Location
- 548 Elm Street, Northampton, Massachusetts 01060
- CMS Provider Number
- 225257
- Inspections on file
- 16
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Care One At Northampton during CMS and state inspections, most recent first.
A resident with a history of urinary retention and other conditions was not properly cared for due to the facility's failure to obtain a urine specimen as ordered by the NP. Despite multiple attempts, the specimen was not collected, and the NP was not notified of the issue. This lack of communication and documentation led to the resident's hospitalization with urosepsis and pneumonia.
A facility failed to maintain accurate medical records for a resident with an order to obtain a urine specimen for a suspected UTI. Despite the order, the specimen was never collected, and the Treatment Administration Record (TAR) showed inconsistencies and lack of documentation. Interviews revealed a lack of communication between shifts and insufficient documentation explaining why the specimen was not obtained.
A resident with severe cognitive impairment and non-weight bearing status was improperly transferred by CNAs without using a mechanical lift, as required by the care plan. This resulted in the resident sustaining a fracture to the left distal femur. The CNAs involved did not check the care card or care plan before performing the transfer, leading to the use of incorrect transfer techniques.
A resident who was non-weight bearing and required a mechanical lift for transfers was improperly transferred by a CNA using a stand/pivot method, resulting in a fracture to the resident's left distal femur. The CNA did not check the care plan or care card before the transfer, which required assistance from two staff members. The resident screamed in pain during the transfer, and the injury was confirmed by an X-ray.
A resident with severe cognitive impairment and multiple medical conditions sustained an injury of unknown origin, which was not reported to the DPH within the required two-hour timeframe. The facility's DON was informed of the injury but delayed the report submission by 48 hours, contrary to the facility's abuse policy.
The facility failed to adhere to infection control practices by not using proper PPE for a resident with a PICC and by allowing unsanitary smoking practices. A nurse did not wear a gown during high-contact care for a resident requiring Enhanced Barrier Precautions, and another nurse lit cigarettes for residents by placing them in her mouth, increasing infection risk.
A facility failed to obtain Physician's orders for the use and care of a TLSO brace for a resident with a spinal fracture. Despite recommendations to wear the brace, the facility lacked documented orders specifying its application and care, confirmed by the DON. This oversight risked inappropriate use and further injury.
The facility failed to provide necessary respiratory care for two residents. One resident did not receive humidified oxygen as ordered, while another received a higher oxygen flow rate than prescribed, leading to elevated blood oxygen saturation levels. These deficiencies were confirmed through observations and staff interviews, indicating a failure to adhere to physician orders and professional standards.
A resident at risk for weight loss, with diagnoses including Major Depressive Disorder and Dysphagia, experienced significant weight decline. Despite this, CNAs inaccurately documented the resident's meal intake, recording higher percentages than observed. Errors were attributed to rushed documentation and training issues, with the RD confirming the resident's poor appetite and low meal consumption.
Failure to Obtain and Communicate Urine Specimen Collection
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding a urine specimen order for a resident suspected of having a urinary tract infection. The Nurse Practitioner (NP) ordered a urine specimen to be obtained on January 14, 2025, but the nursing staff did not successfully collect the specimen. Despite multiple shifts attempting to obtain the sample, there was no documentation of successful collection or notification to the NP about the inability to obtain the specimen. The resident, who had a history of urinary retention, stiff person syndrome, acute focal neurological deficit, and functional neurological system disorder, was not provided with the necessary follow-up care due to the lack of communication. The Treatment Administration Record (TAR) showed various codes indicating attempts and reasons for not obtaining the specimen, but there was no corresponding nursing note or documentation of notifying the NP or physician about the issue. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was not followed. The NP was aware that the specimen had not been obtained by January 15, 2025, but was not informed of the continued failure to collect it. Consequently, the resident experienced a significant decline in health and was admitted to the hospital with a diagnosis of urosepsis and pneumonia on January 18, 2025.
Failure to Maintain Accurate Medical Records for Urine Specimen Collection
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a physician's order to obtain a urine specimen for a suspected urinary tract infection. The order, dated January 14, 2025, required nursing staff to collect the specimen every shift until it was obtained. However, the Treatment Administration Record (TAR) showed inconsistencies and lack of documentation regarding the collection of the specimen. Various codes were used in the TAR, such as checkmarks indicating acknowledgment of the order, but not the completion of the task, and other codes indicating resident refusal or that the resident was asleep. Despite these codes, there was no comprehensive documentation explaining why the specimen was not obtained, except for a single nursing note on January 18, 2025, stating an unsuccessful attempt. Interviews with nursing staff and management revealed that the urine specimen was never collected, and there was a lack of communication between shifts regarding the pending task. The Director of Nursing confirmed that the expectation was for nurses to communicate any uncompleted tasks at shift changes and to document reasons for not obtaining the specimen in the TAR or Nursing Progress Notes. The absence of such documentation and communication led to the failure in obtaining the required urine specimen, resulting in an incomplete medical record for the resident.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the care plan interventions for a resident who required assistance of two staff members and a mechanical lift for transfers due to non-weight bearing status. On a specific date, a Certified Nurse Aide (CNA) transferred the resident using a stand/pivot technique without assistance from another staff member or a mechanical lift, contrary to the care plan. During this transfer, the resident screamed, and it was later determined that the resident sustained a fracture to the left distal femur. The resident, who was admitted to the facility with diagnoses including unspecified dementia, osteopenia, anemia, and macular degeneration, was severely cognitively impaired and dependent on staff for various activities of daily living. The care plan and care card clearly indicated the need for a mechanical lift and assistance from two staff members for transfers. However, the CNA did not check the care card or care plan before transferring the resident, leading to the improper transfer method being used. Further investigation revealed that other CNAs also failed to follow the care plan, as they transferred the resident without using a mechanical lift. The Director of Nurses (DON) confirmed that multiple CNAs did not adhere to the care plan, and it was concluded that the fracture likely occurred during the improper transfer. The facility's internal investigation highlighted the failure to follow established care protocols, resulting in harm to the resident.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was non-weight bearing and required the assistance of two staff members and a mechanical lift for all transfers. On a specific date, a Certified Nurse Aide (CNA) transferred the resident alone from a wheelchair to a bed using a stand/pivot transfer instead of the required mechanical lift. During this transfer, the resident screamed out in pain, and it was later determined that the resident sustained a fracture to the left distal femur. The facility's policy on safe lifting and movement of residents, revised in July 2017, mandates the use of appropriate techniques and devices to lift and move residents, eliminating manual lifting when feasible. The resident's care plan, updated with the Annual Minimum Data Set (MDS) Assessment, indicated a severe cognitive impairment and dependence on staff for various activities of daily living, including transfers. The care plan specifically required the assistance of two staff members with a mechanical lift due to the resident's non-weight bearing status. The CNA involved in the incident had not previously cared for or transferred the resident and did not check the care plan or care card before performing the transfer. The CNA admitted to transferring the resident alone and without the mechanical lift, despite the resident's care plan requirements. The Director of Nurses (DON) confirmed that the fracture likely occurred during this improper transfer, as the resident was non-weight bearing and the transfer was not conducted according to the care plan.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who was admitted in December 2020, had a medical history including dementia, macular degeneration, osteopenia, and iron deficiency anemia. The resident was severely cognitively impaired and dependent on staff for activities of daily living and transfers. On January 13, 2025, the resident complained of left lower extremity pain, and an X-ray was performed, which initially showed no fracture. However, further X-rays on January 14, 2025, revealed an acute impacted distal femur supracondylar fracture. The resident was unable to describe how the injury occurred, and there were no witnesses. The Director of Nurses (DON) was informed of the fracture on January 14, 2025, and determined it to be an injury of unknown source, initiating an investigation per the facility's abuse policy. Despite the policy requiring immediate reporting within two hours for such injuries, the report was not submitted to the DPH until January 16, 2025, 48 hours after the injury was identified. The delay in reporting was acknowledged by the DON, who intended to report the injury immediately but failed to do so in the required timeframe.
Infection Control Deficiencies in PPE Use and Smoking Practices
Penalty
Summary
The facility failed to implement proper infection control practices concerning the use of Personal Protective Equipment (PPE) for a resident with a peripheral inserted central catheter (PICC). The resident, admitted with diagnoses including septic thrombophlebitis and a Methicillin Susceptible Staphylococcus Aureus (MSSA) infection, required Enhanced Barrier Precautions (EBP) during high-contact care activities. Despite the facility's policy and signage indicating the need for gown and glove use, Nurse #3 only donned gloves and a mask while performing PICC care, neglecting to wear a gown. This oversight occurred because Nurse #3 did not notice the EBP sign on the resident's closet door and was unaware of the facility's system of using an orange circle sticker on the nameplate to identify residents on EBP. Additionally, the facility did not maintain a sanitary smoking environment for four resident smokers. During a smoking observation, Nurse #4 was seen lighting cigarettes for residents by placing each cigarette in her mouth before handing it to the residents. This practice was acknowledged by Nurse #4 as a poor infection control practice, as it increased the risk of germ transmission among the residents. The Director of Nursing (DON) confirmed the facility's system for identifying residents on EBP and acknowledged that Nurse #3 should have worn a gown during the PICC care to minimize infection risk. Similarly, the DON stated that Nurse #4 should not have lit the residents' cigarettes by placing them in her mouth, recognizing it as an inappropriate infection control practice.
Failure to Obtain Physician's Orders for TLSO Brace
Penalty
Summary
The facility failed to meet professional standards of practice by not obtaining Physician's orders for the use, management, and care of a Thoracic Lumbar Sacral Orthosis (TLSO) brace for a resident who suffered a fall resulting in a spinal fracture. The resident, admitted with a diagnosis of a wedge compression fracture of the third lumbar vertebrae, was recommended by neurosurgery to wear a TLSO brace at all times except when lying flat. Despite this recommendation, the facility did not have any documented Physician's orders specifying the application, frequency of use, duration of therapy, or care instructions for the TLSO brace. The deficiency was identified through a review of the resident's medical records, which lacked any Physician's orders for the TLSO brace, and was confirmed during interviews with the Director of Nursing (DON). The DON acknowledged the absence of a Physician's order and stated that such an order should have been in place to ensure proper documentation and monitoring of the brace's use, including checking for potential skin issues. This oversight placed the resident at risk for inappropriate use of the TLSO brace and further spinal injury.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two residents. For one resident, who was admitted with chronic respiratory failure and shortness of breath, the facility did not ensure that humidified oxygen was administered as ordered by the physician. Observations revealed that the oxygen concentrator was set to the correct flow rate but lacked a humidifier bottle, which was a requirement per the physician's order. The resident confirmed that a humidifier bottle had never been attached, and the unit manager acknowledged that it was the nurses' responsibility to ensure compliance with the order. Another resident, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was found to have been administered oxygen at a higher flow rate than prescribed. The physician's order specified a continuous flow of one liter per minute to maintain blood oxygen saturation between 88% and 92%. However, observations showed the oxygen concentrator set at two liters per minute, resulting in blood oxygen saturation levels above the ordered parameters. The resident confirmed the incorrect setting, and the unit manager and assistant director of nursing acknowledged the error, noting that the staff failed to follow the physician's order and did not notify the physician when the saturation levels exceeded the prescribed range. These deficiencies highlight the facility's failure to adhere to physician orders and professional standards for oxygen administration, potentially putting residents at risk. The lack of proper equipment and incorrect oxygen flow rates were observed and confirmed by both residents and facility staff, indicating a systemic issue in the management of respiratory care within the facility.
Inaccurate Documentation of Meal Intake for At-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as being at risk for weight loss. The resident, who was admitted with diagnoses including Major Depressive Disorder, Dysphagia, and Altered Mental Status, showed significant weight decline over several months. Despite the resident's poor oral intake and documented weight warnings, the Certified Nurses Aides (CNAs) inaccurately recorded the resident's meal intake percentages. On multiple occasions, the CNAs documented that the resident consumed 75% to 100% of meals, while observations and interviews revealed the resident ate significantly less. The inaccuracies in documentation were attributed to errors made by the CNAs, including one instance where a CNA admitted to documenting in error due to a rushed shift change. Another CNA in training also recorded incorrect meal intake percentages, which were later identified as errors. The Registered Dietician confirmed that the resident had a poor appetite and typically consumed less than 25% of meals, further highlighting the discrepancies in the CNAs' documentation. These documentation errors failed to accurately reflect the resident's nutritional intake, which is critical for monitoring and addressing the resident's risk for weight loss.
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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