Care One At Peabody
Inspection history, citations, penalties and survey trends for this long-term care facility in Peabody, Massachusetts.
- Location
- 199 Andover Street, Peabody, Massachusetts 01960
- CMS Provider Number
- 225323
- Inspections on file
- 18
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Care One At Peabody during CMS and state inspections, most recent first.
The facility failed to secure and properly label medications across three units, leaving treatment carts unlocked and a medication room unsupervised. Unopened insulin was improperly stored, and medication carts were found with spills and unlabeled items. A resident's medications were left unsecured on the floor. Staff interviews confirmed these practices were against facility policies.
A resident with a history of stroke and dysphagia was not provided with built-up utensils during meals, despite physician orders and care plans indicating their necessity. Observations showed the resident eating without assistance, and staff interviews revealed a lack of awareness about the resident's current needs. The care plan and documentation were not updated to reflect the resident's actual level of care, leading to a deficiency.
A resident with heart failure experienced a significant weight gain of 11.4 pounds over four days, but the facility failed to notify the physician as required by the physician's order. Interviews revealed that staff were unaware of the need to notify the physician, highlighting a lapse in communication and documentation.
A facility failed to ensure proper communication and implementation of care for a resident requiring dialysis. The resident had elevated phosphorus levels, but the recommended calcium acetate was not ordered or administered. The responsibility to check the dialysis communication book was not fulfilled, leading to a lack of necessary medication orders. The DON confirmed the need for updating physicians on dialysis center recommendations, which was not done.
The facility failed to maintain sufficient staffing levels to meet residents' personal and cognitive care needs. The CASPER PBJ Staffing Data Report indicated low weekend staffing, and daily schedules from October 2023 to April 2024 showed that most shifts were below expected PPD levels. Interviews with CNAs and a nurse revealed that they were unable to provide timely care due to staffing shortages. The Administrator acknowledged staffing challenges but believed improvements had been made through recruitment efforts.
The facility failed to provide a dignified dining experience on the second and third floor units. Staff were observed referring to residents as 'feeders' and standing while feeding residents, contrary to facility policies. Interviews with the Staff Development Coordinator and DON confirmed these practices were inappropriate.
The facility failed to provide scheduled showers for three residents, supervision during meals for a resident with dysphagia, and timely incontinence care for a resident with severe cognitive impairment. Observations and interviews confirmed these deficiencies, highlighting lapses in care and documentation.
The facility failed to store and prepare food in accordance with professional standards for food service safety. Observations included a staff member without a hair restraint, dented cans, and multiple containers of food that were undated, unlabeled, or past their use-by dates. The Food Service Director confirmed these practices were against policy.
The facility failed to maintain accurate medical records for four residents, including incomplete ADL documentation, incorrect air mattress records, false wound care documentation, and an error in documenting a physician's plan of care for liquid protein supplements.
The facility failed to meet professional standards of quality by not transcribing and implementing physician's orders for wound care and suture removal for three residents. This led to the worsening of a pressure wound, lack of dressing on an arterial wound, and failure to remove sutures as ordered.
The facility failed to provide appropriate hearing treatment and services for two residents. Despite referrals and requests for audiological consultations, neither resident was seen by an audiologist or provided with assistive hearing devices. Staff were unaware of why referrals were not followed up, and the facility's contracted audiology services had not been consistently available.
The facility failed to ensure proper pressure ulcer care and prevention for two residents. One resident did not have a physician's order to discontinue a dressing and air mattress, leading to multiple small open wounds. Another resident's air mattress was not set to the correct settings as ordered, compromising wound management. Staff confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident reported worsening pain and limited range of motion in the right hand, affecting daily activities. Despite the resident's complaints, the nursing summary and care plans did not reflect any impairment, and staff were either unaware or had not observed significant changes. The Occupational Therapist confirmed the resident's condition, but no referral to therapy was made.
The facility failed to maintain acceptable nutrition parameters for two residents, leading to significant weight loss. One resident with Alzheimer's disease experienced an 8.98% weight loss without intervention, while another resident with multiple diagnoses had a 12.08% weight loss that was not timely reweighed or addressed. The facility did not follow its policy for monitoring and addressing significant weight changes.
The facility failed to re-evaluate PRN psychotropic medications after 14 days for two residents with severe cognitive impairments. Both residents had PRN orders for Ativan that lacked end dates, contrary to facility policy. Staff interviews confirmed the oversight.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles across three units. On multiple occasions, treatment carts were left unlocked and unattended, allowing unauthorized access to medicated creams and ointments. Additionally, a medication room was left unsupervised with a surveyor inside, which was against the facility's policy. Interviews with nursing staff and the Director of Nurses confirmed that these practices were not in line with the facility's policies, which require treatment carts to be locked when unattended and medication rooms to be supervised. The facility also failed to properly label and store medications in medication carts on two units. Unopened insulin vials and pens were found in a medication cart instead of being stored in a refrigerator. A bottle of liquid protein was opened without an open date, and there were spills in the medication cart that had not been cleaned. Cleaning wipes were stored with oral medications, and an inhaler was found without a resident label. Interviews with nursing staff and the Infection Preventionist highlighted these discrepancies, noting that medications with shortened expiration dates should be labeled when opened, and cleaning supplies should not be stored with medications. In the case of Resident #90, medications were not secured properly in the resident's room. Approximately eight pills were found on the floor under the resident's bed, which had been knocked off a meal tray by an unidentified staff member. The resident, who was assessed to self-administer medications, reported that the pills had been on the floor for a couple of days and that no staff had returned to remove them. The Director of Nurses confirmed that medications should be secured and not left on the floor, indicating a lapse in adherence to medication security protocols.
Failure to Update Care Plan for Resident with ADL Needs
Penalty
Summary
The facility failed to update the care plan for a resident with a history of stroke and dysphagia, who was admitted in February 2025. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for partial/moderate assistance with meals, including the use of built-up utensils and a lip plate. However, observations over several days revealed that the resident was not provided with built-up utensils during meals, and there was no staff present to assist, despite the resident's physician's orders and care plan indicating the need for such adaptive equipment and assistance. Interviews with staff, including the Speech Language Pathologist (SLP) and the Unit Manager, revealed a lack of awareness and communication regarding the resident's current needs and care plan updates. The SLP noted that the resident should be seated upright during meals and have food cut up, but did not require supervision. The Unit Manager acknowledged that the care plan, physician orders, and documentation did not reflect the resident's current level of care, which should have been updated to indicate that the resident only required meal setup and no longer needed built-up utensils. This discrepancy between the resident's documented needs and the care provided led to the deficiency.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to adhere to professional standards of practice by not implementing a physician's order for a resident with heart failure and chronic respiratory failure. The order required notifying the provider if the resident's daily weight increased by more than two pounds. Despite a significant weight gain of 11.4 pounds over four days, the facility did not notify the physician as required. The resident's daily weights showed a gain of 5.4 pounds on the first day, followed by additional gains over the next three days, yet there was no documentation of physician notification during this period. Interviews with facility staff revealed a lack of awareness and adherence to the physician's order. The Unit Manager was unaware that the physician had not been notified of the resident's weight gain, and the Director of Nursing acknowledged that the physician's orders should have been followed and documented in the nursing notes. This oversight indicates a failure in communication and documentation processes within the facility, leading to the deficiency.
Failure in Communication and Implementation of Dialysis Care Recommendations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring renal dialysis. Specifically, the facility did not ensure complete and accurate communication with the dialysis facility and failed to implement a dietitian's recommendation for phosphate binders. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had elevated phosphorus levels, but there was no physician's order or record of administration for the recommended calcium acetate in the resident's Medication Administration Record. Interviews revealed that it was the responsibility of the medication nurse or unit manager to check the dialysis communication book upon the resident's return from dialysis. However, this was not done, resulting in the absence of an order for calcium acetate. The Director of Nursing confirmed that the nurse or unit manager should update the physician on any orders or recommendations from the dialysis center. The dialysis nurse indicated that communication reports from the dietitian were provided monthly, but the facility failed to act on the recommendations in a timely manner.
Insufficient Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the personal and cognitive care needs of residents. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2024 indicated excessively low weekend staffing. The facility's daily schedules from October to December 2023 and January to April 2024 showed that the majority of weekday and weekend shifts were below the expected staffing levels. Specifically, 59 of 66 weekday shifts and 19 of 27 weekend shifts from October to December 2023, and 65 of 73 weekday shifts and 12 of 28 weekend shifts from January to April 2024, did not meet the facility's expected PPD levels. Interviews with CNAs and a nurse revealed that due to insufficient staffing, they were unable to shower residents, change residents on time, or answer call lights promptly. Additionally, a nurse mentioned that she did not know the residents on her assignment because she had to float around different units due to staffing shortages. The Administrator acknowledged the staffing challenges but believed that significant improvements had been made in recent months through recruitment efforts. Despite these efforts, the daily staffing PPD levels were not consistently met. The Administrator also noted that it is common for staff to complain about insufficient staffing and that the facility staffs according to the census. However, the reported data and staff interviews indicate that the facility did not maintain adequate staffing levels to ensure the safety and well-being of the residents.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience on the second and third floor units. Observations made by the surveyor included staff referring to residents as 'feeders' or 'feeds' while organizing meal carts in the hallway, with other residents sitting nearby. Additionally, a staff member was observed standing over a resident in a wheelchair while feeding them oatmeal, rather than sitting at eye level. These actions were in direct violation of the facility's policies on Assistance with Meals and Dignity, which emphasize the importance of meeting individual needs and providing a dignified dining experience. During interviews, the Staff Development Coordinator and the Director of Nursing both confirmed that staff should not be standing while feeding residents or referring to them as 'feeders' or 'feeds.' The Staff Development Coordinator, who was covering as the third-floor unit manager, reiterated that staff should be sitting at eye level when assisting residents with feeding. These observations and interviews highlight the facility's failure to adhere to its own policies, resulting in a lack of dignity and respect for the residents during meal times.
Failure to Provide ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide assistance for Activities of Daily Living (ADLs) for five residents. Specifically, three residents were not provided with their scheduled showers. Resident #414, who had severe cognitive impairment, was observed with greasy hair and reported not receiving a full shower despite being scheduled for two showers a week. Resident #100, who was cognitively intact but dependent on staff for showering, reported not fitting in the shower chair and not receiving scheduled showers. Resident #19, with severe cognitive impairment, was also not given showers as scheduled, and his spouse confirmed the infrequency of showers. The facility also failed to provide supervision during meals for Resident #95, who had moderate cognitive impairment and required supervision due to dysphagia. Observations revealed that Resident #95 was left unsupervised during meals on multiple occasions, leading to difficulties in eating and potential safety risks. Despite the care plan indicating the need for supervision, staff did not consistently monitor the resident during meal times. Additionally, the facility did not provide timely incontinence care for Resident #61, who had severe cognitive impairment and was frequently incontinent. The resident was observed for five continuous hours without being checked for incontinence, resulting in saturated briefs and an odor of urine. Staff interviews confirmed that residents with incontinence should be checked every two to three hours, but this protocol was not followed for Resident #61.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a surveyor observed a staff member in the food preparation area without a hair restraint, a significantly dented can of marinara on the can rack in the dry storage room, and multiple containers of food in the walk-in refrigerator that were either undated, unlabeled, or past their use-by dates. Additionally, the surveyor found two containers of juice opened but unlabeled in a reach-in refrigerator. Similar issues were observed in the unit kitchenettes on the second, third, and first floors, where opened and undated containers of juice, salads, and resident food were found. Some of the food items showed signs of decomposition, such as browning lettuce in salads. During an interview, the Food Service Director (FSD) confirmed that all food should be labeled when opened or prepared, and that the use-by dates are automatically generated by the label-printing system. The FSD stated that all food items should be discarded after the use-by date and that the dietary department is responsible for regularly checking the kitchenette refrigerators. The FSD also confirmed that all staff members in the food preparation area should wear hairnets at all times and that dented cans should be inspected on delivery and placed in his office for disposal, not on the can rack, to avoid the risk of botulism.
Inaccurate Medical Records Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care documentation. For Resident #100, the facility did not complete daily documentation for Activities of Daily Living (ADLs) for 15 out of 27 nursing shifts. Both the Staff Development Coordinator (SDC) and the Director of Nursing (DON) acknowledged that CNAs should document every shift, and the facility needs a plan to ensure complete documentation across all shifts. For Resident #18, the facility did not accurately document the presence and function of an air mattress. Despite a physician's order to check the air mattress every shift, the Treatment Administration Record (TAR) indicated compliance even though the resident was observed without an air mattress. The Unit Manager admitted to discontinuing the air mattress order without consulting the physician, and both the Assistant Director of Nursing (ADON) and the DON confirmed that the order should not have been marked as implemented if the resident was not on an air mattress. Resident #41's wound care was also inadequately documented. The resident was observed without a dressing on a wound that should have been treated daily according to physician's orders. The Treatment Administration Record falsely indicated that the wound care was completed. Both the ADON and the DON stated that the dressing should not have been documented as completed if it was not done. Additionally, for Resident #61, there was a discrepancy in the documentation of a physician's plan of care for liquid protein supplements. The physician's note to continue the supplements was in error, as the order had been discontinued months earlier. The DON confirmed this documentation error.
Failure to Implement Physician's Orders for Wound Care and Suture Removal
Penalty
Summary
The facility failed to provide services that met professional standards of quality for three residents. For Resident #61, the facility did not transcribe and implement the physician's updated orders for a pressure wound treatment. Despite the physician's recommendation to change the dressing, the resident continued to receive the incorrect treatment, leading to the worsening of the wound, including the development of eschar and increased pain. The Assistant Director of Nursing (ADON) acknowledged that the order was not transcribed and the incorrect dressing was applied for several days. For Resident #41, the facility did not implement the physician's order to apply a dressing to an arterial wound. The resident was observed without a dressing on multiple occasions, and the resident reported that the nurse had not applied the dressing due to being too busy. The Treatment Administration Record (TAR) falsely indicated that the dressing had been applied as ordered. Interviews with staff confirmed that the dressing should have been in place and that the resident had not refused care. For Resident #214, the facility failed to remove sutures from the resident's nose as ordered by the physician. The resident reported that the sutures were not removed on the scheduled date, and the Medication Administration Record (MAR) incorrectly showed that the order had been completed. The Unit Manager and Director of Nursing (DON) confirmed that the sutures should have been removed and that there was no documentation of the resident refusing the procedure.
Failure to Provide Audiology Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for two residents, Resident #91 and Resident #41. Resident #91, who has moderate cognitive impairment and requires total dependence on staff for activities of daily living, reported difficulty hearing and expressed a desire to see an ear doctor. Despite a referral being placed with the contracted audiology service in September 2022, there were no records indicating that Resident #91 was ever seen by an audiologist or provided with assistive hearing devices. The Unit Secretary and other staff members were unaware of why the referral was not followed up, and the Director of Nursing acknowledged that the referral should have been addressed given the time elapsed since it was made. Resident #41, who was admitted with diagnoses including dementia and anemia, also experienced issues related to hearing. Despite a request for an audiological consultation being made in August 2023, there were no records indicating that Resident #41 was seen by an audiologist or provided with hearing aids or amplifiers. Observations and interviews revealed that Resident #41 had significant difficulty hearing, which affected their ability to communicate and participate in activities. Staff members had to repeat questions multiple times and adjust their volume to communicate with Resident #41, who expressed a desire for hearing aids. The facility's contracted audiology services had not been consistently available, with the last visit recorded in November 2023. The Unit Secretary and Director of Nursing acknowledged the lack of follow-up on audiology referrals and the need for alternative interventions for residents with hearing impairments. Despite audits being conducted since January 2024, the facility had not ensured that residents received the necessary audiology services or assistive devices, leading to ongoing issues for both Resident #91 and Resident #41.
Failure to Ensure Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in treatment and services. For Resident #18, the facility did not obtain a physician's order to discontinue a dressing for a recently healed pressure ulcer and failed to obtain a physician's order to discontinue an air mattress ordered for skin integrity management. Despite the resident's high risk for skin breakdown, the air mattress was removed without a replacement, and the wound treatment order lacked an end date or instructions for discontinuation. The resident was observed with multiple small open wounds, and staff confirmed the absence of a dressing and air mattress, which were discontinued without physician approval. For Resident #71, the facility did not ensure that the air mattress was set to the correct settings for a resident with multiple pressure ulcers. The air mattress pump was consistently observed at the wrong setting, contrary to the physician's order, which specified a different setting for effective wound management. Staff interviews confirmed that the air mattress should have been set to the correct setting as ordered, but this was not implemented. These deficiencies highlight the facility's failure to adhere to professional standards of practice in managing pressure ulcers, including obtaining necessary physician orders and ensuring proper use of prescribed equipment. The lack of adherence to these protocols resulted in inadequate care for residents at high risk for skin breakdown and pressure ulcers.
Failure to Address Decrease in Range of Motion
Penalty
Summary
The facility failed to identify and provide interventions for a decrease in range of motion for a resident. The resident, admitted with diagnoses including heart failure and stroke, reported difficulty in straightening fingers on the right hand, which had worsened over the past few months. Despite the resident's complaints of pain and reduced ability to perform tasks, the nursing summary and care plans did not reflect any impairment in range of motion or contractures. The most recent Occupational Therapy evaluation also failed to indicate any issues with the resident's right hand. Interviews with the resident and staff revealed that the resident's right-hand fingers had limited range of motion and increased pain, affecting daily activities. The resident's second and fifth fingers could only open to approximately 75% of full range of motion, while the third and fourth fingers could only straighten to about 50%. The resident had to adapt to using utensils differently due to the impairment. Staff members, including nurses and CNAs, were either unaware of the resident's condition or had not observed any significant changes. The Occupational Therapist confirmed that the resident's right-hand fingers were stuck in a bent position and that the resident experienced more pain and less range of motion than previously noted. The Director of Nursing and the Director of Rehabilitation both stated that nursing should have made a referral to therapy if a change in range of motion was observed. However, no such referral was made, and the resident's condition was not adequately addressed in the care plan or through therapy interventions.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition status for two residents, leading to significant weight loss. For Resident #69, who was admitted with Alzheimer's disease and severe cognitive impairment, the facility did not identify or implement an intervention for a significant weight loss of 8.98% over a period of approximately two months. Despite the resident being on hospice services, the Registered Dietitian (RD) was not alerted to the weight loss, and no intervention was put in place. Interviews with the RD, Staff Development Coordinator (SDC), and Director of Nursing (DON) revealed that the facility's process for monitoring and addressing weight changes was not followed, resulting in the oversight of the resident's significant weight loss. For Resident #29, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3, and vascular dementia, the facility failed to reweigh the resident in a timely manner to confirm a significant weight loss of 12.08% within a month. The resident's care plan included interventions for nutrition-related medication management and regular weight monitoring. However, the RD requested a reweigh 20 days after the initial significant weight loss was documented, and no interventions were implemented during this period. Interviews with the RD, SDC, and DON indicated that the facility did not adhere to its policy of promptly reweighing residents to verify significant weight changes and implement necessary interventions. Both cases highlight a failure in the facility's procedures for monitoring and addressing significant weight loss in residents. The facility's policy required timely reweighing and notification of the RD and physician for significant weight changes, but these steps were not followed, resulting in unaddressed weight loss for both residents. The lack of timely intervention and communication among staff contributed to the deficiencies observed in the care of Residents #69 and #29.
Failure to Re-evaluate PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two residents. Resident #49, who was admitted with diagnoses including dementia, dysphagia, and major depressive disorder, had a PRN order for Lorazepam that did not include an end date. The Unit Manager confirmed that PRN orders for Ativan should have a stop date and require re-evaluation by the doctor. Similarly, Resident #69, admitted with Alzheimer's disease, had a PRN order for Ativan that also lacked an end date. The Staff Development Coordinator, acting as Unit Manager, acknowledged that psychotropic medications used on a PRN basis need to be re-evaluated after 14 days and should include a clinical reason for continued use and an end date for further re-evaluation. Interviews with staff revealed a lack of adherence to the facility's policy on psychotropic medication use, which mandates that PRN orders for such medications are limited to 14 days and require documentation for any extension. Both residents were assessed to have severe cognitive impairments, and the failure to re-evaluate their PRN psychotropic medications as required by policy was confirmed by multiple staff members, including the Unit Manager and the Staff Development Coordinator.
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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