Care Village At Mattapan
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattapan, Massachusetts.
- Location
- 405 River Street, Mattapan, Massachusetts 02126
- CMS Provider Number
- 225532
- Inspections on file
- 15
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Care Village At Mattapan during CMS and state inspections, most recent first.
Nursing staff did not document a urinary catheter change for a resident with neuromuscular bladder dysfunction, despite physician orders and the procedure being performed due to catheter blockage. The nurse involved confirmed the omission, and the DON acknowledged that catheter care was not properly recorded in the medical record.
The facility failed to adhere to physician orders and recommendations for several residents, including not following up on a clinic referral, not obtaining orders for air mattress settings, and not holding tube feeding during a resident's absence. Additionally, heel booties were not used as ordered, and documentation inaccurately reflected care provided.
The facility failed to follow food safety standards by storing dented cans on the can rack and not labeling or dating opened food in the refrigerator. Dented cans, which pose a botulism risk, were not set aside for return, and opened meats were found undated and unlabeled, contrary to facility policy. Interviews with staff confirmed these lapses in protocol.
The facility failed to maintain accurate medical records for several residents, including incorrect MRSA diagnosis, improper blood pressure documentation, and errors in enteral feeding records. A resident's record contained information from another resident, and staff interviews confirmed these documentation issues.
A resident with severe cognitive impairment was observed lying topless in bed with the privacy curtain and door open, exposing them to the hallway. Despite a care plan intervention to assist with the privacy curtain, staff failed to maintain the resident's dignity and privacy. Interviews with staff revealed awareness of the issue, but the resident was repeatedly exposed, indicating non-compliance with facility policy.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was not reported to the physician by the nursing staff. Despite the resident's complaints and observations of worsening edema, the nurse did not notify the physician, citing it as normal for the resident. The physician and nurse practitioner were unaware of the condition, indicating a failure to follow the facility's policy on notifying changes in condition.
A resident with severe cognitive impairment was found in a room with dead cockroaches and a soiled brief on the floor. Despite expectations for daily cleaning, the facility failed to maintain a clean and homelike environment, as confirmed by interviews with the DON and Corporate Nurse.
A resident with intact cognition reported observing their roommate using drugs and alcohol, but the facility failed to investigate the allegations. The resident was discouraged from submitting a grievance, and the grievance book did not document any investigation into the report, contrary to the facility's policy.
The facility failed to complete Significant Change in Status MDS assessments for two residents. One resident experienced significant weight loss, urinary catheter removal, and developed a stage 4 pressure ulcer, while another was admitted to hospice care. Both changes required assessments within 14 days, which were not completed, indicating a lapse in adherence to assessment protocols.
A facility failed to document a resident's indwelling urinary catheter in the MDS assessment, despite the resident having a neuromuscular dysfunction of the bladder and being observed with a catheter. Physician orders and treatment records confirmed the catheter's use, and staff interviews acknowledged the oversight.
A facility failed to create a baseline care plan within 48 hours of admission for a resident with acute embolism and deep vein thrombosis. The medical record review showed the absence of a timely care plan, and a Unit Manager confirmed the necessity of completing it within two days to guide caregivers.
A facility failed to create a comprehensive care plan for a resident with end-stage renal disease and osteomyelitis, lacking plans for dialysis and skin impairment. Despite physician orders for dialysis and wound care, the care plans did not address these needs. A Unit Manager confirmed the necessity for a person-centered care plan triggered by the MDS.
A resident with severe cognitive impairment and dysphagia was left without supervision during meals, despite their care plan indicating the need for assistance. Facility staff were unaware of the care plan requirements, leading to a deficiency in providing necessary ADL support.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was reported to nursing staff but not communicated to medical personnel. Despite visible swelling, the condition was not addressed until eight days later when an ultrasound was ordered to rule out a DVT.
A resident with impaired vision and a recommendation for cataract surgery did not receive the necessary follow-up care in a timely manner. Despite being cognitively intact and expressing a desire to proceed with surgery, the facility failed to schedule a follow-up appointment with an ophthalmologist. Interviews with staff revealed a lack of awareness and action regarding the resident's need for cataract surgery, highlighting a deficiency in the coordination of care.
A facility failed to follow a physician's order for air mattress settings for a resident with pressure ulcers. The resident, with multiple sclerosis and stage 3 and 4 pressure ulcers, was observed with the air mattress set at 100 pounds instead of the ordered 150 pounds. The care plan required the mattress to be set as ordered, and staff interviews confirmed the need for regular checks.
A facility failed to administer continuous enteral feeding as ordered for a resident with multiple sclerosis and dysphagia. The resident, who was cognitively intact, went on a leave of absence for seven hours without receiving the prescribed feeding. The medical record lacked documentation of physician notification regarding the feeding interruption, and staff interviews confirmed the oversight.
The facility failed to ensure proper respiratory care for two residents, resulting in unlabeled and improperly stored oxygen and nebulizer tubing. One resident's oxygen concentrator filter was dusty, and another resident's nebulizer equipment was not stored in a bag. Staff interviews confirmed that labeling and proper storage were required but not adhered to.
A resident with severe cognitive impairments and schizophrenia did not receive a required psychiatric consult or enrollment in psychiatric services, despite being on antipsychotic medications and exhibiting aggressive behavior. The facility failed to follow through on a physician's order for psychological evaluation and treatment, and the Director of Nursing was unaware of the oversight.
A facility failed to conduct an AIMS assessment for a resident receiving antipsychotic medications, as required by policy. The resident, with severe cognitive impairment and diagnoses including schizophrenia, was prescribed Haldol and Olanzapine. Despite recommendations from the consultant pharmacist, the medical record lacked evidence of the assessment, and staff interviews confirmed the oversight.
The facility failed to follow proper infection control practices, as observed when a CNA exited a resident's room with soiled linen while wearing the same gloves used to bag the linen. The CNA walked through the hallway and disposed of the linen in the chute before removing the gloves, contrary to infection control standards. The Infection Preventionist confirmed that gloves should not be worn in hallways and must be removed with hand hygiene performed before entering the hallway.
Failure to Document Urinary Catheter Change
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident with Cauda Equina Syndrome and neuromuscular bladder dysfunction. The resident had physician orders allowing nursing staff to change an indwelling urinary catheter as needed for blockage or dislodgement. Despite these orders, there was no documentation in the resident's medical record or Treatment Administration Record (TAR) indicating that a catheter change occurred during the relevant period. An internal investigation revealed that a nurse changed the resident's Foley catheter at the resident's request due to discomfort and blockage, but did not document the procedure anywhere in the medical record. The nurse confirmed during an interview that the catheter change was performed but not recorded. The Director of Nursing also acknowledged that the catheter change should have been documented and that daily care related to indwelling catheters was not being properly recorded.
Failure to Adhere to Physician Orders and Recommendations
Penalty
Summary
The facility failed to meet professional standards of practice for several residents, as evidenced by the lack of adherence to physician recommendations and orders. For one resident, the facility did not follow a physician's recommendation to send the resident to an HIV clinic to confirm their diagnosis and determine necessary treatment. Despite the physician's recollection of making the recommendation, there was no documentation to support that an appointment was made or attended. Another resident was observed using an air mattress without a physician's order or care plan specifying the appropriate settings. The Director of Nursing acknowledged that an order or care plan should have been in place. Similarly, another resident had a physician's order for an air mattress with specific settings, but observations revealed that the mattress was not set correctly, and the Director of Nursing confirmed that settings should be checked every shift. Additionally, the facility failed to obtain a physician's order to hold tube feeding for a resident who was away from the facility, despite the resident's inability to eat by mouth. The nursing staff acknowledged that an order should have been in place. Furthermore, another resident did not have physician's orders for heel booties and elevation of heels implemented, as the booties were found unused, and the treatment administration record inaccurately indicated that the treatment was provided.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. In the main kitchen storage room, several significantly dented cans, including carrots, beef stew, and tropical fruit salad, were found on the can rack, contrary to the facility's policy that dented cans should be set aside in the office for return due to the risk of botulism. Additionally, in the main kitchen refrigerator, an opened ham roast and a pan of cooked meat in juices were found undated and unlabeled, which is against the facility's policy requiring all refrigerated foods to be covered, labeled, and dated. Interviews with the cook and the Food Service Director confirmed these practices were not followed, highlighting a lapse in food safety protocols.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, leading to several deficiencies. For one resident, the facility inaccurately maintained a diagnosis of MRSA despite hospital discharge paperwork indicating a negative result for the infection. This discrepancy was further complicated by the physician's uncertainty about the resident's MRSA status. Another resident's medical record failed to document the correct location for blood pressure measurements, as the care plan specified measurements should be taken on the left leg due to vascular implants, yet records showed measurements were taken on the arms multiple times. Additionally, a resident's medical record contained a progress note from another resident, indicating a failure to ensure that medical records included information pertaining only to the individual resident. Furthermore, the facility inaccurately documented the enteral feeding intake for another resident who was on a feeding tube, with inconsistencies noted in the medication administration record, especially when the resident was away from the facility. These inaccuracies were acknowledged by the nursing staff during interviews, highlighting a lack of adherence to proper documentation protocols.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #3, who was observed lying topless in bed with both the privacy curtain and the bedroom door open, exposing the resident to the hallway. This incident occurred despite the facility's policy on dignity and quality of life, which mandates staff to promote and protect resident privacy, including bodily privacy during care and treatment procedures. Resident #3, who has severe cognitive impairment and requires assistance with activities of daily living, has a care plan that acknowledges a preference for lying naked in bed and includes an intervention to assist with the privacy curtain as needed. During interviews, Nurse #2 acknowledged the dignity issue and mentioned that Resident #3 is known to pull open the curtain with a stick, although the stick could not be located during the survey. The nurse also noted the difficulty in closing the bedroom door due to the preferences of the resident's roommate. The Director of Nursing confirmed that the expectation is for the privacy curtain to be closed if a resident is exposed. Despite these acknowledgments, the resident was again observed topless with the curtain and door open, indicating a failure to adhere to the care plan and facility policy.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who exhibited edema in the left leg. The resident, who has a history of embolism and hemiplegia, reported increased leg swelling and pain to the occupational therapist, but no action was taken. Observations confirmed the swelling, and interviews revealed that the nursing staff did not notify the physician or nurse practitioner, despite the resident's complaints and the worsening condition. Nurse #2 acknowledged the swelling but did not consider it significant enough to report, attributing it to the resident's normal condition. However, the resident's medical record did not indicate any existing condition that would cause such edema. Rehab staff confirmed that they had informed Nurse #2 about the swelling, but the information was not relayed to the physician. The physician and nurse practitioner were unaware of the resident's condition, indicating a breakdown in communication and failure to follow the facility's policy on physician notification for changes in condition.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident who was admitted in October 2010 with diagnoses including anemia and severe cognitive impairment. The resident, who requires assistance with activities of daily living, was observed on multiple occasions lying in bed surrounded by approximately 6-7 dead cockroaches. Additionally, a soiled brief was found on the floor next to the resident during two separate observations. Interviews with the Director of Nursing and the Corporate Nurse revealed that housekeeping is expected to clean rooms daily and address pest issues as needed, indicating a lapse in maintaining the resident's environment.
Failure to Investigate Resident's Report of Drug and Alcohol Use
Penalty
Summary
The facility failed to investigate a report of drug and alcohol use as reported by a resident. The resident, who was admitted with diagnoses including atrial fibrillation, chronic pain, and anxiety disorder, had a BIMS score indicating intact cognition. The resident reported to a prior social worker that they observed their roommate using drugs in the bathroom and consuming alcohol in the room. The resident was advised to submit a grievance but was discouraged from writing their account, leading them to believe that the report would not be investigated. Consequently, the resident did not submit a grievance. Interviews with the Corporate Nurse and the Director of Nursing revealed that they were unaware of the report. The Corporate Nurse later confirmed that the prior social worker had noted the resident's reluctance to submit a grievance due to perceived inaction. A grievance was recorded in the grievance book, but it only mentioned the resident's dissatisfaction with their roommate and visitors, without addressing the drug and alcohol use allegations. The grievance book lacked documentation of any investigation into the resident's report, indicating a failure to follow the facility's policy on investigating allegations of abuse.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to adequately identify and assess significant changes in the status of two residents, leading to deficiencies in care. For one resident, the facility did not complete a Significant Change in Status Minimum Data Set (MDS) assessment despite the resident experiencing significant weight loss, the removal of an indwelling urinary catheter, and the development of a stage 4 pressure ulcer. The resident's medical records indicated ongoing issues with weight loss and the presence of a pressure ulcer, which were not self-limiting, yet no significant change assessment was initiated within the required 14-day period. Another resident was admitted to hospice care, a change that also required a Significant Change in Status MDS assessment. However, the facility failed to complete this assessment within the mandated timeframe. The resident had been diagnosed with malignant neoplasm of the temporal lobe, depression, and dementia, and was severely cognitively impaired. The decision to admit the resident to hospice care was documented, but the necessary assessment to reflect this significant change in status was not conducted. Interviews with facility staff revealed a lack of adherence to the guidelines outlined in the Resident Assessment Instrument (RAI) manual. The Director of Nursing indicated that the MDS nurse was responsible for monitoring residents for significant changes, but the assessments were not completed as required. The corporate nurse acknowledged that a significant change MDS should have been completed for the resident admitted to hospice care, highlighting a gap in the facility's compliance with assessment protocols.
MDS Assessment Fails to Reflect Indwelling Catheter Use
Penalty
Summary
The facility failed to accurately reflect the status of a resident when the Minimum Data Set (MDS) assessment did not indicate the presence of an indwelling urinary catheter. The resident, admitted in May 2023 with neuromuscular dysfunction of the bladder, was observed with a urinary catheter drainage bag on February 11, 2025. Despite this, the MDS assessment dated January 16, 2025, did not document the use of the catheter. The resident's physician orders and treatment administration records confirmed the use of a Foley catheter since May 2023. Interviews with nursing staff and a corporate nurse corroborated the presence of the catheter, highlighting the discrepancy in the MDS documentation.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan within the required 48 hours of admission for a resident, leading to a deficiency. The resident was admitted in January 2025 with diagnoses including acute embolism and deep vein thrombosis of the left upper extremity. A review of the medical record showed that a baseline care plan was not completed within the specified timeframe. During an interview, a Unit Manager confirmed that a baseline care plan should be completed within two days of admission to guide caregivers on the resident's care needs.
Failure to Develop Comprehensive Care Plan for Dialysis and Skin Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident with end-stage renal disease and osteomyelitis. The resident, who was admitted with diagnoses including renal dialysis dependence and a surgical wound, did not have a care plan addressing dialysis or the actual skin impairment upon admission. The Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, was on dialysis, and had a surgical wound with infections. Physician orders specified dialysis on certain days and care for the dialysis catheter site and left foot dressing. However, the care plans did not reflect these needs. During an interview, a Unit Manager acknowledged that the resident should have a person-centered care plan for dialysis and skin impairment, triggered by the MDS completion.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, specifically in the area of meal supervision. The resident, who was admitted with diagnoses including dementia, dysphagia, and schizophrenia, was observed on multiple occasions sitting with a breakfast tray without any staff present to assist or supervise, despite the care plan indicating the need for such support. The resident's most recent Minimum Data Set (MDS) indicated severe cognitive impairment, further underscoring the need for assistance. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan. A Certified Nursing Assistant (CNA) and a nurse both stated that the resident did not require supervision or assistance with eating, contradicting the care plan. The Director of Nurses (DON) confirmed that the care plan should be followed if it indicates the need for supervision or assistance. This discrepancy between the care plan and staff actions led to the deficiency in providing appropriate care for the resident's ADLs.
Failure to Address Edema in Resident
Penalty
Summary
The facility failed to address a change in condition related to edema management for a resident who was admitted with a history of embolism and hemiplegia. The resident, who had intact cognition, reported increased leg swelling and pain in the left calf to the occupational therapist, but no action was taken. Observations noted the resident's left leg was large and swollen, and the medical record did not indicate any edema or related diagnoses. Despite the resident's complaints and visible swelling, the nursing staff did not notify the nurse practitioner or physician, assuming the condition was normal for the resident. Interviews with staff revealed that the resident's leg swelling was known but not communicated to the appropriate medical personnel. Nurse #2 acknowledged the swelling but did not consider it necessary to inform the nurse practitioner or physician. Rehab staff confirmed that they had notified Nurse #2 about the swelling, but no further action was taken. The nurse practitioner and physician were unaware of the condition until eight days after the initial report, when an ultrasound was finally ordered to rule out a deep vein thrombosis.
Failure to Follow Up on Cataract Surgery Recommendation
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain their vision. Specifically, the facility did not follow up on a recommendation for cataract surgery for a resident who was admitted with diagnoses including stiff man syndrome and anxiety. The resident, who is cognitively intact with a BIMS score of 15 out of 15, was noted to have impaired vision and did not use corrective lenses. A consultant eye doctor had recommended cataract surgery and a follow-up with an ophthalmologist within 3-4 months, but the facility did not document any follow-up actions or consultations regarding this recommendation. The resident expressed during interviews that their vision had worsened since admission and that they were responsible for making their own healthcare decisions. Despite the resident's desire to proceed with cataract surgery, there was no evidence in the medical record of any follow-up or scheduled appointments. Interviews with facility staff, including a nurse and the Director of Nurses, revealed a lack of awareness and action regarding the necessary follow-up for the resident's cataract surgery, indicating a failure in communication and coordination of care within the facility.
Failure to Follow Physician's Order for Air Mattress Settings
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice by not adhering to a physician's order regarding air mattress settings for a resident with pressure ulcers. The resident, who was admitted with multiple sclerosis and stage 3 and 4 pressure ulcers on the back and sacrum, was observed on two occasions with the air mattress set at 100 pounds, contrary to the physician's order of 150 pounds. The care plan specified that the air mattress should be set as ordered to aid in pressure redistribution. Interviews with the Director of Nursing and a nurse confirmed that the air mattress settings should be checked every shift to ensure compliance with the physician's order.
Failure to Administer Continuous Enteral Feeding as Ordered
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident diagnosed with multiple sclerosis, dysphagia, and gastrostomy status. The resident, who was cognitively intact, was observed to have gone on a leave of absence from the facility for seven hours without receiving the prescribed enteral feeding. The physician's order required the resident to receive continuous enteral feeding of Osmolite 1.5 at 55 ml/hour for 24 hours a day, which was not followed during the resident's absence. The medical record did not indicate that the physician was notified about the interruption in the resident's enteral feeding. Interviews with the nursing staff confirmed that the resident should have been receiving the feeding continuously and that the physician should have been informed if the resident did not receive the feeding as ordered. This oversight in communication and adherence to the physician's order led to the deficiency identified by the surveyors.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in labeling, dating, and maintaining respiratory equipment. For one resident, who was admitted with anemia and severe cognitive impairment, the oxygen tubing was not labeled or dated, and the oxygen concentrator's filter was covered in dust. This was observed on multiple occasions, and it was noted that the night nurse was responsible for changing the tubing weekly, while maintenance was tasked with changing the filters. Another resident, admitted with chronic pain syndrome and lack of coordination, had nebulizer tubing that was not labeled with a date and was not stored properly in a bag. Despite being cognitively intact, the resident's nebulizer equipment was observed to be improperly stored and unlabeled on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that respiratory equipment should be labeled, dated, and stored correctly, but these procedures were not followed.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #28, who was admitted with diagnoses including dementia without behaviors, dysphagia, and schizophrenia. The resident was receiving antipsychotic medications, Haldol and Olanzapine, but did not receive a psychiatric consult as required. The resident's physician had ordered a psychological evaluation and treatment for adjustment to the need for placement in the facility and medication management if required. However, the facility did not ensure that the psychiatric consult was completed, and the resident was not enrolled in psychiatric services. The deficiency was further highlighted when the resident exhibited aggressive behavior, attempting to throw a computer and trying to open a back door forcefully. Despite these incidents, the facility did not follow through with the necessary psychiatric evaluation. The Director of Nursing was unaware that the request for psychiatric services form was blank in the resident's chart and that the resident had not been enrolled in psychiatric services. Additionally, a Consultant Pharmacist had recommended an AIMS evaluation, but this was not completed, and the resident was not seen by psychiatric services as required.
Failure to Conduct AIMS Assessment for Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications and properly assessed for adverse reactions to psychotropic medications. Specifically, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving antipsychotic medications, Haldol and Olanzapine, initiated in December 2024. The facility's policy required an AIMS assessment every six months for residents on antipsychotic medications, but the resident's medical record did not indicate that such an assessment was completed. The resident, who was admitted with diagnoses including dementia without behavioral disturbance, dysphagia, and schizophrenia, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Despite the consultant pharmacist's recommendation to perform an AIMS evaluation, the resident's medical record lacked evidence of this assessment. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed that AIMS assessments were expected to be completed by psych services but were not documented in the resident's records.
Infection Control Breach: Improper Glove Use
Penalty
Summary
The facility failed to adhere to proper infection control practices, which increased the risk of contamination and spread of infection among residents. During observations on two separate occasions, a certified nursing aide was seen exiting a resident's room with a bag of soiled linen while wearing the same gloves used to bag the linen. The aide then walked through the hallway and disposed of the dirty linen in the linen chute before removing the potentially contaminated gloves. This practice was contrary to the infection control standards, as confirmed by the Infection Preventionist, who stated that gloves should not be worn in hallways and staff should remove gloves and perform hand hygiene before entering the hallway.
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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