Care One At Redstone
Inspection history, citations, penalties and survey trends for this long-term care facility in East Longmeadow, Massachusetts.
- Location
- 135 Benton Drive, East Longmeadow, Massachusetts 01028
- CMS Provider Number
- 225299
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Care One At Redstone during CMS and state inspections, most recent first.
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 a severe onion allergy was served a meal containing onions despite clear documentation of the allergy on the meal ticket and in the medical record. The resident had selected an alternate meal, but due to failures in the dietary and nursing staff's process for checking meal tickets and verifying tray contents, the resident received and consumed a meal with onions, resulting in an anaphylactic reaction that required emergency intervention and hospitalization.
A resident with severe cognitive impairment and a history of falls was kept in a wheelchair with a Velcro self-releasing seatbelt during supervised meals and activities, without the restraint being released as required. Staff did not consistently assess or document the resident's ability to self-release the seatbelt each shift, and required restraint assessments were not completed. Facility leadership confirmed these lapses and acknowledged the seatbelt should have been considered a restraint.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
Three residents with indwelling urinary catheters did not receive care in accordance with physician orders and facility policy. Two residents had catheters of the wrong size placed, contrary to medical orders, and another resident did not have a required securement device in place. These deficiencies were confirmed through observation, record review, and staff interviews.
A resident with moderate cognitive impairment and dietary restrictions was not consistently provided with a requested peanut butter and jelly sandwich for dinner, despite this preference being documented and communicated by the dietitian. The resident often went without dinner when the sandwich was not provided, and staff interviews confirmed the preference should have been honored according to policy.
Staff failed to follow infection control protocols, including proper use of PPE and hand hygiene, when caring for a resident on contact precautions for C-diff and during disposal of soiled materials by a hospice staff member. Observed lapses included not wearing a gown during incontinence care and improper glove removal and disposal, increasing the risk of infection transmission.
A resident with dementia, depression, and PTSD had a large crack in their bedroom window that remained unrepaired for 84 days after it was reported. The concern was raised by the resident's representative and communicated to the administrative team, but there was no evidence of a timely maintenance request or follow-up, resulting in the window remaining cracked at the time of survey.
A resident with epilepsy did not receive multiple scheduled doses of anti-convulsant medications due to unavailability, and nursing staff failed to notify the provider as required by facility policy. Documentation did not reflect any provider notification for the missed doses, and interviews confirmed that the expected communication and documentation procedures were not followed.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications because the medications were not available from the pharmacy. Nursing staff documented the unavailability and contacted the pharmacy, but there was no evidence of further action to secure the medications, resulting in missed doses as confirmed by the DON.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to unavailability, as confirmed by MAR review and staff interviews. Nursing staff reported contacting the pharmacy for delivery, but medications were not received in time, resulting in missed doses and non-compliance with physician orders.
A resident with hypokalemia did not receive multiple doses of a prescribed potassium supplement because the medication was unavailable from the pharmacy, and nursing staff failed to notify the provider as required by facility policy. The resident was later hospitalized with low potassium levels and mental status changes. Interviews confirmed that staff did not inform the provider about the missed doses, and there was no documentation of such notification.
A resident with hypokalemia and other medical conditions did not receive a prescribed potassium and sodium phosphate supplement for several days due to the medication not being available, ongoing pharmacy delivery issues, and incomplete communication and documentation by nursing staff. The pharmacy required a signed OTC form, which was not provided, and there was no clear record of follow-up actions taken to obtain the medication.
The facility failed to follow proper sanitation and food handling practices, risking foodborne illness. Dietary aides did not wear required beard restraints, and one aide used gloved hands to serve food without changing gloves or performing hand hygiene, leading to potential cross-contamination. The FSD acknowledged the need for serving utensils and proper hygiene.
The facility failed to notify the provider about ineffective pain management for two residents. One resident did not receive timely alternative pain medication when Morphine was unavailable, and another resident's severe pain was not communicated to the provider despite ineffective medication. Staff interviews confirmed the expected protocol was not followed, leading to prolonged pain for the residents.
Two residents experienced deficiencies in care at the facility. One resident's PICC line dressing was not changed as ordered, and catheter measurements were not documented, risking complications. Another resident did not receive a scheduled medication for 24 days due to unavailability, and the physician was not notified. Additionally, the medication was administered incorrectly. These issues highlight failures in following facility policies and communication protocols.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications and notify providers for alternative solutions. One resident did not receive their prescribed morphine due to pharmacy delays, and the staff failed to contact the provider for an emergency order. Another resident's pain medications were ineffective, yet the facility did not monitor or adjust the pain regimen, leaving the resident in constant pain.
A resident, capable of making their own decisions, was not allowed to sign their medical documents, including the MOLST form, which was signed by their representative instead. The resident, who was cognitively intact, expressed a desire to sign their own paperwork and needed assistance due to visual deficits. They were also unaware of ancillary services offered and requested a review of these options.
A facility failed to accurately complete a Level I PASARR for a resident with Bipolar Disorder and a history of Behavioral Health Services, resulting in the omission of a required Level II PASARR Evaluation. The screening incorrectly indicated no mental illness or recent mental health services, which was later acknowledged as an error by the social worker.
The facility failed to conduct required care plan meetings for two residents, violating their policy. One resident, admitted in 2012 with depression and diabetes, had no documented care plan meetings despite being cognitively intact. Another resident, admitted in 2024 with dementia and diabetes, also had no care plan meetings since admission. Staff interviews confirmed these oversights.
A resident who requested audiology services upon admission in 2021 was not seen by an audiologist, despite expressing concerns about hearing. The facility's Medical Records Clerk noted scheduling issues with the contracted provider, and the administrator was unaware of the oversight.
A resident with PTSD was not provided with trauma-informed care as the facility failed to assess and identify PTSD triggers or develop a care plan upon admission. Despite the resident's cognitive intactness and the facility's policy requiring such assessments, these steps were overlooked until identified by a surveyor.
The facility failed to timely implement Consultant Pharmacist recommendations for two residents. One resident on antipsychotic medication did not receive recommended assessments and monitoring, while another resident's inhaler administration orders were not updated to include a rinse parameter to prevent thrush. These delays indicate a breakdown in communication and follow-up within the facility's medication management process.
A resident with severe pain and multiple health conditions received incorrect opioid medication on two occasions due to errors by two nurses. The nurses administered the wrong form of Morphine Sulfate, deviating from the physician's orders, which posed a risk of sedation and respiratory depression. Both nurses were educated on medication administration rights, but one expressed uncertainty about preventing future errors.
The facility failed to maintain sanitary conditions in medication storage areas on two units. Inspections revealed a wet, reddish-brown substance in the refrigerators of both the Kensington and [NAME] Units, posing a risk of medication contamination. Staff acknowledged the need for cleaning.
A facility failed to obtain physician-ordered lab work and diagnostic tests for a resident on antipsychotic medication with a history of breast cancer. Despite orders for an annual EKG, mammogram, and specific lab tests, there was no evidence these were completed. Interviews confirmed the absence of these tests since their initial order.
A facility failed to maintain accurate medical records for a resident with dementia regarding their Advanced Directives. The resident's MOLST form indicated DNR/DNI, but the Physician's orders and Advanced Directives Care Plan were inconsistent, with the latter incorrectly stating the resident wished to be a full code. The Unit Manager confirmed the discrepancy, acknowledging the need for the records to reflect the resident's documented wishes.
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 Prevent Exposure to Known Food Allergen Resulting in Anaphylaxis
Penalty
Summary
A resident with a documented severe allergy to onions, including airborne exposure, was served a meal containing onions despite clear documentation of the allergy in the medical record, care plan, and on the meal ticket. The resident had previously experienced an anaphylactic reaction to onions, and the allergy was well known to both dietary and nursing staff. On the day of the incident, the resident had selected an alternate meal that should not have contained onions, and the meal ticket specifically indicated the allergy and listed foods to avoid. Despite established facility policies requiring multiple checks of meal tickets for allergies during food preparation and tray line service, the resident was inadvertently served the main meal of taco salad, which contained onions in the salsa mixed with the ground beef. Staff interviews revealed that the process for reading and verifying meal tickets was not properly followed, and the resident's tray was not checked as required before being delivered. The dietary staff involved in meal preparation and tray assembly did not identify the error, and the nursing staff did not catch the mistake before the tray was delivered to the resident. After consuming a portion of the meal, the resident developed symptoms of anaphylaxis, including shortness of breath, tachycardia, low oxygen saturation, and altered mental status. Emergency intervention was required, including administration of epinephrine and transfer to the hospital, where the resident was admitted for further treatment. The incident was attributed to multiple failures in the facility's system for identifying and preventing exposure to known food allergens.
Failure to Release and Evaluate Use of Velcro Seatbelt Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically by not releasing a Velcro self-releasing seatbelt during supervised activities and meals, and by not evaluating or documenting the resident's ability to self-release the seatbelt every shift. The resident, who had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, was observed multiple times with the seatbelt secured while under direct supervision during meals and activities. Despite the facility's policy requiring restraints to be used only when necessary for medical symptoms and to be the least restrictive option, the seatbelt remained in place even when the resident was supervised and not exhibiting impulsive behaviors. Additionally, the care plan and physician's orders required staff to prompt and document the resident's ability to self-release the seatbelt every shift, but nursing progress notes did not show evidence of this documentation. Interviews with facility leadership confirmed that the resident's ability to self-release was inconsistent and that required quarterly restraint assessments were not completed as scheduled. The DON acknowledged that the seatbelt should have been considered a restraint due to the resident's fluctuating mental status and inconsistent ability to self-release.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, are not provided in the report excerpt.
Failure to Follow Physician Orders and Securement Protocols for Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services related to indwelling urinary catheters for three residents. For two residents with chronic medical conditions requiring Foley catheters, staff did not follow physician orders regarding the correct catheter size. In both cases, the residents had 16 French (Fr) catheters in place, while the physician orders specified 18 Fr catheters. This discrepancy was confirmed by both the unit manager and nursing staff during direct observation and review of the residents' records and orders. Additionally, another resident with a history of urinary retention and an indwelling catheter did not have a securement device in place as required by physician orders and facility policy. During multiple observations, no securement device was found securing the catheter tubing, and the resident reported never having had such a device. The unit manager acknowledged the absence of the securement device and indicated awareness of the issue during the survey. The facility's own policy requires adherence to physician orders for catheter size and the use of securement devices to prevent complications. The failure to follow these orders and policies was directly observed and confirmed through interviews and record reviews, resulting in deficiencies in catheter care for the affected residents.
Failure to Honor Resident's Documented Dietary Preference
Penalty
Summary
The facility failed to honor a resident's stated dietary preference for a peanut butter and jelly sandwich with every dinner meal, despite this preference being documented on the resident's dietary slip. The resident, who was moderately cognitively impaired but able to communicate and understand, reported that he or she could not tolerate regular dinner meals due to stomach upset and had repeatedly requested the sandwich as a substitute. The resident stated that the sandwich was only provided once or twice a week, and when it was not included on the dinner tray, the resident would not eat dinner. The resident also expressed reluctance to repeatedly ask staff for the sandwich, as the request had already been made and documented. Interviews with facility staff, including the dietitian and Food Service Director, confirmed that the resident's preference was known and should have been honored according to facility policy. The dietitian acknowledged the importance of providing the requested sandwich to prevent nutritional complications and confirmed that the information had been communicated to the dietary team. Despite this, the dietary staff did not consistently provide the sandwich as requested, resulting in the resident missing dinner meals when the preference was not met.
Failure to Adhere to Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices on two units, as evidenced by direct observations and staff interviews. On one unit, a resident with a diagnosis of Enterocolitis due to Clostridium difficile (C-diff) was under contact precautions, as indicated by physician orders and signage outside the resident's room. Despite these precautions, a Unit Manager provided incontinence care to the resident while wearing only gloves and not a gown, as required by the facility's policy for contact precautions. The Unit Manager acknowledged during an interview that a gown should have been worn to prevent the spread of infection. On another unit, a hospice staff member was observed exiting a resident's room while wearing contaminated gloves and carrying soiled materials. The staff member disposed of the soiled items in the utility room but improperly removed her gloves, placing them in her shirt pocket instead of discarding them in the trash. The gloves subsequently fell to the floor, were picked up, and returned to her pocket. The staff member admitted she did not perform hand hygiene after glove removal, contrary to facility policy. Interviews with facility leadership confirmed that staff are expected to follow established infection control protocols, including the use of appropriate PPE and hand hygiene. The Director of Nursing also stated that outside providers, such as hospice staff, should be educated on facility infection control policies prior to providing care, but this had not occurred in this instance.
Failure to Timely Repair Cracked Window in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring the timely repair of a cracked bedroom window for one resident. The issue was first reported by the resident's representative during a care plan meeting, where concerns about a large crack in the window were raised. The facility's social worker communicated this concern to the administrative team on the same day. However, there was no evidence in the unit's maintenance request book that a formal request for repair was made at that time. The cracked window remained unrepaired for 84 days after it was initially reported. Interviews with facility staff revealed a lack of awareness and follow-through regarding the maintenance request. The maintenance worker only became aware of the issue after being informed by the administrator several weeks later, at which point the process to obtain a vendor for repair was initiated. Despite payment for the repair eventually being made, the window remained cracked and unrepaired at the time of the surveyor's observation. The resident involved had diagnoses including non-Alzheimer's dementia, depression, and PTSD.
Failure to Notify Provider of Missed Anti-Convulsant Doses
Penalty
Summary
Nursing staff failed to notify the provider when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered. The facility's policy required nurses to inform the attending physician or on-call physician when there was a significant need to alter medical treatment or when a resident refused treatment or medication two or more consecutive times. Despite this, there was no documentation that the provider was notified on multiple occasions when the resident missed doses of Oxcarbazepine and Lamotrigine. Review of the Medication Administration Record (MAR) for the month showed that the resident did not receive several scheduled doses of Oxcarbazepine and Lamotrigine, with nurses documenting the missed doses using a code indicating 'other, see nursing note.' However, nurse progress notes did not contain evidence that the provider was informed about these missed doses. Interviews with nursing staff confirmed that medications were not administered because they were not available, and the provider was not notified as required by facility policy. The Director of Nursing acknowledged that the expectation was for nurses to notify the provider and document both the notification and the provider's response in the nurse's notes when medications were unavailable. This process was not followed, resulting in a failure to communicate significant changes in the resident's medication regimen to the provider as required.
Failure to Provide Prescribed Anti-Convulsant Medications Due to Pharmacy Supply Issues
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by their provider. The resident had physician's orders for Oxcarbazepine and Lamotrigine, both used to treat seizures, with specific dosages and administration times. Review of the Medication Administration Record (MAR) for the month showed multiple instances where the resident did not receive these medications, with nurses documenting that the medications were not available and noting 'on order' or similar explanations in the nursing progress notes. Nursing staff reported that they contacted the pharmacy when medications were unavailable, but there was no documentation of further steps taken to ensure the medications were obtained. Interviews with nurses revealed ongoing issues with pharmacy supply, including delays in delivery, limited quantities being sent, and long wait times when contacting the pharmacy. Despite repeated calls and documentation of the issue, the resident continued to miss doses of their prescribed medications on several occasions. The Director of Nursing confirmed that the resident was not administered the prescribed doses of Oxcarbazepine and Lamotrigine because the medications were not available from the pharmacy. The facility's policy required that residents have a sufficient supply of medications and that nursing staff communicate with the pharmacy and take responsibility for obtaining medications when not available, but these procedures were not effectively followed in this case.
Failure to Administer Anti-Convulsant Medications as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by the physician. The resident's medication orders included Oxcarbazepine 300 mg in the morning and evening, and Lamotrigine 400 mg once daily. Review of the Medication Administration Record (MAR) for the month showed multiple missed doses of both Oxcarbazepine and Lamotrigine on specific dates, with documentation confirming that the medications were not administered as prescribed. Interviews with nursing staff revealed that the missed doses were due to the unavailability of the medications at the facility. Nurses reported that they contacted the pharmacy for delivery, but the medications were not delivered in time for administration. The staff acknowledged that missing doses of anti-convulsant medications could place the resident at risk for seizures, and that a certain blood level of these medications is required to prevent such events. The Director of Nursing confirmed that the medication errors were a result of delayed medication deliveries from the pharmacy, which prevented timely administration according to physician orders. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, but this was not followed due to the lack of medication availability.
Failure to Notify Provider of Missed Potassium Supplement Doses
Penalty
Summary
Nursing staff failed to notify the provider when a resident with a history of hypokalemia did not receive prescribed potassium and sodium phosphate supplements due to the medication being unavailable from the pharmacy. The resident was admitted with diagnoses including hypokalemia, metabolic encephalopathy, influenza, and RSV, and had a physician's order for potassium supplementation to address low potassium levels. According to the medication administration record, the resident missed multiple doses of the ordered supplement over several days, with nurses documenting that the medication was not received from the pharmacy. There was no documentation that the provider was notified after the missed doses, despite facility policy requiring notification after two or more consecutive missed doses or when a significant alteration in treatment is needed. Interviews with nursing staff and facility leadership confirmed that the provider was not informed about the missed doses, and the nurse practitioner stated she would have considered alternative treatments if notified. The unit manager and director of nursing both indicated that staff are expected to notify the provider if a resident misses multiple doses of a medication. The resident was later transferred to the hospital with new onset mental status changes and was found to have a significantly low potassium level, requiring intravenous potassium treatment.
Failure to Provide Prescribed Potassium Supplement Due to Pharmacy and Communication Issues
Penalty
Summary
A deficiency occurred when a resident with a history of hypokalemia and other significant diagnoses was not provided with a prescribed potassium and sodium phosphate supplement as ordered by their physician. The medication was ordered to be administered twice daily, but documentation showed that the resident did not receive any doses over several days. Nursing staff recorded that the medication was not available and that the pharmacy had been contacted, but there was inconsistent or incomplete documentation regarding the communication with the pharmacy and the steps taken to resolve the issue. Interviews with nursing staff and the unit manager revealed ongoing issues with the facility's pharmacy, including delays in medication delivery, medications being out of stock or on backorder, and inconsistent communication from the pharmacy. The pharmacy manager stated that the medication in question was considered an over-the-counter (OTC) product and that their policy required a signed OTC form from the facility before dispensing, which they had not received. The pharmacy manager also indicated that, according to their records, the medication order was never sent to the facility. Further review of the resident's medical record did not show evidence that nursing staff documented detailed communications with the pharmacy regarding the missing medication. The director of nursing confirmed that the medication was not stocked in the facility's emergency supply and acknowledged inconsistent communication with the pharmacy. As a result, the resident did not receive the ordered medication for several days, and there was a lack of clear documentation and follow-up regarding the delay.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which are essential to prevent foodborne illnesses. During a dinner service observation, three dietary aides with facial hair were not wearing beard restraints, contrary to the facility's policy that mandates hair and beard restraints to prevent contamination. The Food Service Director (FSD) was under the impression that beard restraints were only necessary for facial hair longer than 1/4 inch, which was inconsistent with the facility's policy. Additionally, a dietary aide was observed using gloved hands to serve food, but failed to change gloves or perform hand hygiene after handling various items, including unwrapped dinner rolls and a utility cart. This practice posed a risk of cross-contamination. The FSD acknowledged that serving utensils should be used to prevent potential contamination, and that proper hygiene practices were not followed during the observed dinner service.
Failure to Notify Provider of Ineffective Pain Management
Penalty
Summary
The facility failed to notify the physician or provider in a timely manner regarding the need to alter treatment for two residents, leading to deficiencies in pain management. For one resident, the facility did not inform the physician when the ordered pain medication, Morphine Sulfate, was unavailable from the pharmacy, despite the resident experiencing severe pain rated at 8 out of 10. The nursing staff did not contact the on-call provider to obtain an emergency order for alternative pain medication from the facility's emergency kit, as expected by the facility's policy. Another resident experienced ineffective pain management with their prescribed medication regimen, which included Morphine Sulfate and Dilaudid. The resident's pain was consistently rated between 8 and 10 out of 10, indicating severe pain, yet there was no documented evidence that the provider was notified of the ineffectiveness of the pain management plan. The facility's policy required staff to communicate with the provider when pain interventions were not effective, but this was not done. Interviews with nursing staff and management confirmed that the expected protocol was not followed in both cases. The Director of Nursing and Nurse Practitioner acknowledged that the staff should have contacted the on-call provider to address the residents' unrelieved pain. The lack of communication with the provider resulted in prolonged pain for the residents, contrary to the facility's pain management policy.
Deficiencies in PICC Line Care and Medication Management
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident, the facility did not complete PICC device dressing changes as ordered by the physician, failed to measure the external catheter length as required, and did not notify the provider in a timely manner when changes in the catheter length and arm circumference were identified. This resident was admitted with diagnoses of pneumonia with lung abscess and sepsis, and the lack of proper care placed them at risk for complications such as undiagnosed infiltration and deep vein thrombosis. The resident reported that the PICC dressing was not changed regularly, and observations confirmed that the dressing was not dated, and measurements were not documented as per the physician's orders. Another resident experienced a failure in medication management. The facility did not take the required steps when a scheduled medication was unavailable from the pharmacy for 24 days, including failing to notify the physician of the continued non-availability of the medication. Additionally, the medication was not administered via the correct route as prescribed. This resident had a history of depression, delirium, psychotic disturbance, mood disturbance, dementia, anxiety, and insomnia. The medication in question, ABH gel, was not available for an extended period, and there was no documented evidence that the physician was notified to obtain alternative orders. The facility's policies on central venous catheter care and unavailable medications were not followed, leading to these deficiencies. The staff did not document or communicate changes in the resident's condition or medication availability, which are critical components of resident care. Interviews with staff revealed a lack of recent training and awareness of the facility's procedures, contributing to the oversight in care and medication management.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. For one resident, the facility did not administer the prescribed pain medication for severe pain due to unavailability from the pharmacy. The staff did not contact the physician or provider for an emergency order or alternative pain medication, resulting in the resident experiencing prolonged severe pain. The resident was given Ativan, which is not a pain medication, and the facility did not document any communication with the provider regarding the unavailability of the prescribed medication. Another resident experienced ineffective pain management, as the prescribed pain medications did not alleviate their severe pain. The facility failed to monitor the effectiveness of the pain medication and did not notify the physician or provider for evaluation and modification of the pain regimen. The resident reported constant pain, and the clinical records showed that follow-up pain assessments indicated the medication was ineffective, yet no additional interventions were offered, nor was the provider contacted. Interviews with staff and review of clinical records revealed that the facility did not adhere to its pain management policy, which requires immediate contact with the prescriber if pain is not adequately controlled. The staff did not document offering additional doses or contacting the provider for further orders, leading to unrelieved pain for the residents.
Failure to Allow Resident to Sign Medical Documents
Penalty
Summary
The facility failed to ensure that a resident, who was capable of making their own decisions, was given the opportunity to review and sign documents related to their medical care. The resident was admitted with a diagnosis of cerebral infarction without residual effects and was identified as cognitively intact with a BIMS score of 15 out of 15. Despite this, the resident's representative signed the Request for Services Form and the MOLST form, which should have been signed by the resident themselves. The resident expressed a desire to sign their own paperwork and indicated that due to visual deficits, they would need assistance in reviewing the documents. Additionally, the resident could not recall if ancillary services such as dental, eye/vision care, and foot care were discussed or offered to them. They were unaware if their representative had signed paperwork for these services and expressed a desire for someone from the facility to review the options with them. The resident mentioned the possibility of needing new eyeglasses and dental care, suggesting that if these services were discussed upon admission, they might not have been fully aware due to their condition at the time.
Failure to Complete Accurate PASARR Screening
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is necessary to determine if a resident has an intellectual or developmental disability and/or serious mental illness requiring further evaluation. The resident in question was admitted with diagnoses of Bipolar Disorder and Adjustment Disorder, and had a history of utilizing Behavioral Health Services. Despite this, the PASARR Level I Screening incorrectly indicated that the resident did not have a documented diagnosis of a mental illness or disorder, nor had they required mental health services in the past two years. This inaccuracy in the PASARR Level I Screening led to the omission of a required Level II PASARR Evaluation, which should have been conducted to assess the need for specialized services. The error was identified during a review of the resident's Social Service Admission Evaluation and the PASARR completed upon admission. The social worker acknowledged that the PASARR was not completed correctly, and that the resident's diagnosis and history of receiving behavioral health services should have prompted a Level II evaluation.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided the right to participate in the care plan process, as required by their policy. Specifically, for two residents, the facility did not conduct the necessary care plan meetings. The policy mandates that an interdisciplinary team (IDT), along with the resident and their representative, develop and implement a comprehensive, person-centered care plan. This plan should be reviewed and updated quarterly or when there are significant changes in the resident's condition. However, the facility did not adhere to these requirements for the residents in question. Resident #2, who was admitted in January 2012 with diagnoses including depression and type 2 diabetes mellitus, was cognitively intact with a BIMS score of 14 out of 15. Despite this, there was no documented evidence of care plan meetings or participation by the resident or their representative between specific periods in 2022 and 2023. Interviews with facility staff revealed that the required care plan meetings did not occur, and there was no documentation to indicate that the resident or their representative refused to participate. Resident #122, admitted in January 2024 with diagnoses including dementia, depression, and type 2 diabetes mellitus, was moderately cognitively impaired with a BIMS score of 9 out of 15. The facility failed to conduct any care plan meetings for this resident since their admission, as required. Staff interviews confirmed that the care plan meetings were overlooked, and there was no evidence of meetings occurring after the resident's admission or following the MDS assessment in April 2024.
Failure to Arrange Audiology Services for Resident
Penalty
Summary
The facility failed to arrange an audiology appointment for a resident who expressed concerns about their hearing. The resident, admitted in December 2021, had requested audiology services upon admission, as documented in the Request for Services Form. Despite this request and a care plan noting potential communication difficulties due to hearing loss, the resident had not been seen by an audiologist. A nursing progress note from April 2024 indicated concerns from the resident and their family about hearing the television, leading to a treatment with Debrox to address ear wax, which was found to be absent after treatment. Interviews with facility staff revealed that the resident was not scheduled for audiology services, despite being enrolled since 2021. The Medical Records Clerk, responsible for scheduling, noted discrepancies in the contracted provider's census sheet and mentioned that the provider sometimes failed to visit as scheduled. The facility administrator was unaware of the oversight, indicating a breakdown in communication and follow-up regarding the resident's audiology needs.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a history of Post Traumatic Stress Disorder (PTSD). The resident, who was admitted in May 2024, had a diagnosis of PTSD and was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. Despite this, the facility did not complete an assessment to identify the resident's PTSD triggers, nor did they develop a care plan to address these triggers, as required by their policy on Trauma-Informed and Culturally Competent Care. Interviews with the Director of Social Services and a Social Worker revealed that the necessary trauma-informed care assessment was not conducted upon the resident's admission, and no care plan was developed to manage the resident's PTSD. This oversight was only identified when brought to the facility's attention by a surveyor. The facility's policy mandates universal screening for trauma exposure and the development of individualized care plans in collaboration with the resident and family, which was not adhered to in this case.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely responses to Consultant Pharmacist recommendations for two residents. For one resident, the facility did not implement recommendations related to the use of antipsychotic medication. The resident, who had severe cognitive impairment and was on antipsychotic medication, required an AIMS test, orthostatic blood pressure measurements, and a psychiatric evaluation. These recommendations were initially made on December 29, 2023, and repeated on February 28, 2024, due to lack of response. The psychiatric evaluation was eventually completed on February 19, 2023, and orthostatic blood pressure monitoring was initiated on April 12, 2024, indicating significant delays in addressing the recommendations. Another resident, admitted with asthma, was prescribed Symbicort inhalation aerosol. The Consultant Pharmacist recommended adding a rinse parameter to the administration orders to prevent thrush, a potential side effect of the medication. This recommendation was made on April 15, 2024, but was not implemented in the resident's care plan. The DON acknowledged that the Unit Managers were responsible for reviewing and addressing the Pharmacist's recommendations, but the necessary update to the physician's order was not made. The facility's policy requires that the Consultant Pharmacist's findings and recommendations be reported to relevant staff and addressed in a timely manner. However, in these cases, the recommendations were not acted upon promptly, leading to deficiencies in the care provided to the residents. The delay in implementing the recommendations highlights a breakdown in communication and follow-up within the facility's medication management process.
Medication Errors in Opioid Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of opioid pain medication. Two nurses, Nurse #10 and Nurse #9, administered the incorrect form of Morphine Sulfate on separate occasions, which deviated from the physician's orders. This error placed the resident at risk for sedation and respiratory depression. The resident involved was admitted with multiple serious conditions, including osteomyelitis of the vertebra, and stage 3 and 4 pressure ulcers. The resident was cognitively intact and experienced severe, almost constant pain, which significantly affected their daily activities and sleep. The physician's orders included various forms of Morphine Sulfate, both extended-release and short-acting, to manage the resident's pain effectively. On two occasions, the nurses administered the wrong type of Morphine Sulfate. Nurse #10 mistakenly gave an extended-release tablet instead of a short-acting tablet, and Nurse #9 administered an extended-release tablet instead of an oral solution. Both errors were documented in the facility's Medication Error Reports, and the nurses involved were educated on the rights of medication administration. However, during interviews, Nurse #10 expressed uncertainty about preventing future errors, indicating a potential gap in understanding or application of the medication administration protocols.
Medication Storage Sanitation Deficiency
Penalty
Summary
The facility failed to maintain medication storage in a sanitary manner on two units, Kensington and [NAME], as observed by surveyors. During an inspection of the Kensington Unit medication room refrigerator, a wet, reddish-brown substance was found dripping down the interior back wall onto a shelf where medications were stored. The Unit Manager acknowledged the refrigerator was dirty and needed cleaning. Similarly, on the [NAME] Unit, the refrigerator was observed to have water dripping and a reddish-brown substance pooling along the back interior edge and floor, where medications were stored. The nurse confirmed the need for cleaning to prevent contamination of medications.
Failure to Obtain Required Lab Work and Diagnostic Testing
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory work and diagnostic testing were obtained for a resident who was prescribed an antipsychotic medication and had a history of breast cancer. The resident, admitted in January 2012, had diagnoses including Schizoaffective Disorder-Bipolar Type, Morbid Obesity, and a history of Breast Cancer. The physician's orders from June 2024 included an annual electrocardiogram (EKG) due to the use of Abilify, an annual mammogram screening, and yearly lab work including TSH and Free T4 levels. However, there was no documented evidence that these tests were completed as ordered. Interviews with the Unit Manager revealed that the resident's TSH and Free T4 levels were not obtained, and there was no annual mammogram or EKG scheduled as required. The Unit Manager confirmed the absence of evidence for the completion of these tests since they were ordered by the physician in January 2019. This oversight in obtaining necessary lab work and diagnostic testing constitutes a deficiency in the facility's compliance with physician orders and resident care requirements.
Inaccurate Medical Records for Advanced Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident diagnosed with dementia, specifically regarding their Advanced Directives. The resident had a MOLST form signed, indicating their wishes for Do Not Resuscitate (DNR) and Do Not Intubate (DNI). However, the June 2024 Physician's orders did not reflect these wishes, and the Advanced Directives Care Plan inaccurately stated that the resident wished to be a full code, which contradicted the MOLST form. During an interview, the Unit Manager acknowledged the discrepancy, noting that the MOLST form accurately reflected the resident's wishes, but the Advanced Directives Care Plan was incorrect and should have indicated DNR/DNI. Additionally, the Physician's orders should have been updated to align with the resident's MOLST form, as the resident's wishes were clearly documented as DNR/DNI.
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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