Care Village At West Roxbury
Inspection history, citations, penalties and survey trends for this long-term care facility in West Roxbury, Massachusetts.
- Location
- 5060 Washington Street, West Roxbury, Massachusetts 02132
- CMS Provider Number
- 225499
- Inspections on file
- 21
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Care Village At West Roxbury during CMS and state inspections, most recent first.
A resident with hypothyroidism was observed self-administering thyroid medication without a proper assessment for their ability to do so safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which was not followed. Nursing staff confirmed the resident should have been supervised while taking medication, but this was not consistently done.
A resident's MDS assessment inaccurately coded a pressure ulcer as stage 2, despite documentation of granulation tissue, which is inconsistent with stage 2 ulcers. Interviews with staff confirmed the error, and the importance of using the RAI manual for accurate coding was emphasized.
The facility failed to follow physician orders for two residents. One resident's urinary catheter drainage bag was not changed as prescribed, with discrepancies in the schedule and documentation. Another resident did not have offloading boots applied as ordered, despite records indicating compliance. Staff interviews revealed lapses in adherence to care plans and documentation.
A facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea by not consistently applying the physician-ordered CPAP machine at bedtime. Observations showed the CPAP was not in use, and staff interviews confirmed it was not applied. The resident's care plan lacked CPAP use instructions, and there were no cleaning orders, contrary to facility policy.
The facility failed to create individualized PTSD care plans for two residents. One resident, admitted in 2020, had no PTSD care plan despite an active diagnosis. Another resident, admitted in 2023, had a PTSD diagnosis but lacked a care plan identifying triggers, as confirmed by the DON.
A resident with moderate cognitive impairment and multiple diagnoses was observed with bed rails positioned incorrectly, contrary to the physician's order and assessment. The facility's policy requires bed rails to be used as mobility aids, not restraints, and mandates proper assessment and informed consent. However, staff interviews and observations revealed that the rails were consistently positioned in the middle of the bed, not in the upper 1/4 as required, indicating a failure to adhere to guidelines and orders.
A facility failed to address a consultant pharmacist's recommendations to clarify conflicting Tylenol PRN orders for a resident with moderate cognitive impairment. Despite repeated recommendations, both orders were administered without clarification, and the DON acknowledged the oversight.
A facility failed to properly store medications on a nursing unit, leaving vials of an IV antibiotic unlocked and unattended at the nurses' station. Staff interviews confirmed the medications were for a specific resident, and the DON acknowledged the oversight, which violated the facility's medication storage policy.
The facility failed to date and dispose of expired refrigerated foods as required by its policy. During a kitchen inspection, a surveyor found undated containers and an expired pan of caramel sauce in the refrigerator. The Food Service Director acknowledged that all refrigerated foods should have expiration dates and that expired items must be discarded.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. A resident with dementia did not receive documented steri strip treatment, while another resident with diabetes had incomplete wound descriptions in assessments. Staff interviews revealed inconsistencies in following facility policies on skin audits and pressure ulcer prevention.
The facility failed to maintain a clean and homelike environment in the shower rooms of two resident units. Observations revealed dirty tile grout, missing floor tiles, a missing drain cover, and the presence of dead and live insects. Staff interviews confirmed the need for repairs and cleaning to uphold the facility's policy of providing a safe and comfortable environment.
A facility failed to support a resident's right to self-determination by permanently revoking their smoking privileges after multiple incidents of possessing smoking paraphernalia. Despite the resident's requests to resume smoking under supervision, the facility maintained the revocation due to non-compliance with its smoking policy.
A resident with a history of PTSD and other conditions was restrained by staff during the confiscation of a vape pen, leading to a deficiency. The resident reported being attacked, and the facility's investigation confirmed that staff held the resident down to remove the vape pen, which was hidden under their clothing. The actions were considered overly aggressive, violating the facility's policy on physical restraints.
A resident with a complex medical history alleged assault by staff during a vape pen confiscation. Despite being informed of the resident's intention to report the incident to the police, a nurse failed to notify the Administrator immediately, leading to a delay in addressing the allegations. The Administrator only learned of the situation when police arrived hours later.
A severely cognitively impaired resident was involved in a verbal altercation with a CNA, during which profane language was used by both parties. The incident was witnessed by two nurses, leading to the termination of the CNA after an internal investigation.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without a proper assessment. The resident, who was admitted with a diagnosis of hypothyroidism, was observed self-administering a thyroid medication without having been assessed for the ability to do so safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for residents who wish to self-administer medications, but this process was not followed for the resident in question. The resident was observed with a medication cup containing a pill, which they identified as their morning thyroid medication. The resident stated that the nurse usually leaves the medication for them to take independently. However, the resident's medical records indicated that the medication was to be administered by nursing staff, and there was no documentation of an assessment for self-administration. Interviews with nursing staff confirmed that the resident should have been supervised while taking their medication, but this was not consistently done.
Inaccurate MDS Assessment for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, specifically in coding the correct stage of a pressure ulcer. The resident, who was admitted with diagnoses including diabetes and nutritional anemia, had a pressure ulcer on the coccyx documented in the hospital discharge summary. The MDS assessment inaccurately coded the ulcer as a stage 2, despite documentation indicating the presence of granulation tissue, which is not characteristic of a stage 2 ulcer. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed the presence of granulation tissue in the pressure ulcer, which should have precluded a stage 2 classification. The MDS Nurse acknowledged the error, stating that the MDS was not completed accurately. The Director of Nursing emphasized the importance of using the Resident Assessment Instrument (RAI) manual for accurate coding, highlighting a lapse in following proper assessment protocols.
Failure to Implement Physician Orders for Catheter Care and Offloading Boots
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with the comprehensive care plan and professional standards of quality for two residents. For Resident #217, the facility did not implement the physician's order to change the urinary catheter drainage bag as prescribed. The physician's order specified that the catheter bag should be changed weekly on Mondays and Thursdays during the night shift. However, the nursing staff only scheduled the change for Thursdays, and the surveyor observed that the catheter bag had not been changed since 10/20/24, despite a record indicating it was changed on 10/24/24. Nurse #5 could not recall changing the bag on the specified date, and the Director of Nursing confirmed that the order should have been followed. For Resident #62, the facility failed to follow the physician's orders to apply offloading booties to the resident's heels while in bed. The physician's order required the boots to be worn at all times, but the surveyor observed the resident lying in bed with heels directly on the mattress on multiple occasions. The Treatment Administration Record inaccurately indicated that the boots were worn during these times, with only three documented refusals. Nurse #1 acknowledged the responsibility to ensure the boots were on and to document any refusals, while the Director of Nursing noted that the resident often kicked the boots off.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident diagnosed with obstructive sleep apnea, heart failure, and shortness of breath. The resident was admitted to the facility with a physician's order for a continuous positive airway pressure (CPAP) machine to be used at nighttime. However, observations and interviews revealed that the CPAP machine was not consistently applied at bedtime as ordered. The CPAP was often found wrapped in a plastic bag on the nightstand with a dry water chamber, indicating it was not in use. The resident reported that staff did not offer or apply the CPAP at bedtime, and the Treatment Administration Record inaccurately documented the application of the CPAP. Interviews with staff, including a Certified Nurse Assistant and a nurse working the overnight shift, confirmed that the resident did not wear the CPAP at night. The Director of Nursing acknowledged that nursing staff should follow the physician's orders and apply the CPAP, and noted that the resident was aware of their needs. Additionally, the resident's care plan did not include the use of the CPAP, and there were no orders for cleaning the machine, which are required as per the facility's policy.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for residents diagnosed with post-traumatic stress disorder (PTSD). Resident #17, admitted in August 2020, had an active diagnosis of PTSD as indicated in their quarterly behavioral assessment and Minimum Data Set (MDS) assessment. However, a review of their medical records revealed that a PTSD care plan had not been developed. During an interview, the MDS Nurse confirmed that a care plan should have been created for this diagnosis. Similarly, Resident #29, admitted in November 2023, also had a diagnosis of PTSD. Their MDS assessment showed they were cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS). Despite this, their plan of care did not include a personalized PTSD care plan identifying any triggers. The Director of Nursing acknowledged that the PTSD care plan was integrated with the psychotropics plan of care but should have specifically identified triggers that could exacerbate symptoms.
Improper Implementation of Bed Rails for Resident
Penalty
Summary
The facility failed to ensure that bed rails were implemented in accordance with the bed rail assessment and physician's order for a resident with moderate cognitive impairment and multiple diagnoses, including hemiplegia and diabetes. The resident was observed multiple times with bilateral side rails positioned in the middle of the bed, contrary to the physician's order and assessment, which specified the use of 1/4 bedrails for mobility and transfers. The facility's policy on the use of side rails emphasizes their use as mobility aids rather than restraints and requires a thorough assessment and informed consent. Despite the policy, the resident's bed rails were not positioned as assessed and ordered, leading to a discrepancy between the intended use and actual implementation. Interviews with staff, including a CNA and a nurse, confirmed that the side rails were consistently positioned in the middle of the bed. The Director of Nursing and Director of Operations also observed the incorrect positioning, noting that the rails were not in the upper 1/4 of the bed as required. This inconsistency highlights a failure in adhering to the facility's guidelines and the physician's order, potentially impacting the resident's safety and care.
Failure to Address Pharmacist Recommendations for Medication Orders
Penalty
Summary
The facility failed to address recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist in a timely manner for a resident. The facility's policy requires that the consultant pharmacist's observations and recommendations regarding residents' medication therapies be communicated and responded to appropriately and timely. However, for a resident with moderate cognitive impairment and multiple diagnoses, including hemiplegia and diabetes, the recommendations to clarify two conflicting Tylenol as needed (PRN) pain orders were not acted upon. The pharmacist's notes from September and October indicated the need to clarify which Tylenol order should remain active to avoid medication errors. Despite the consultant pharmacist's recommendations being documented and communicated to the Director of Nursing (DON) and Medical Director, the facility did not act on these recommendations. The resident's Medication Administration Record (MAR) showed that both Tylenol orders were administered on multiple occasions in September and October, without clarification or discontinuation of one of the orders. During an interview, the DON acknowledged that the recommendations were not acted upon as they should have been, indicating a lapse in the facility's process for addressing pharmacist recommendations.
Improper Storage of Medications on Nursing Unit
Penalty
Summary
The facility failed to ensure that all medications were stored in accordance with accepted professional principles of practice. Specifically, on the [NAME] Unit, a plastic container containing vials of ampicillin sulbactam, an intravenous antibiotic medication, was observed to be unlocked and unattended at the nurses' station. This occurred on multiple occasions over two days, as noted by the surveyor's observations. Interviews with nursing staff revealed that the medications in the plastic container were intended for a specific resident, Resident #62. Despite this, the medications were not properly secured, as confirmed by the Director of Nursing, who acknowledged that the IV antibiotics should not have been left unlocked and unattended. This oversight indicates a failure to adhere to the facility's policy on the safe and secure storage of medications.
Failure to Date and Dispose of Expired Refrigerated Foods
Penalty
Summary
The facility failed to adhere to its policy on food storage and labeling, as observed during a surveyor's inspection of the kitchen. The inspection revealed three undated plastic containers in the refrigerator, one labeled as pasta sauce, and two unlabeled containers with a reddish-brown liquid and an opaque liquid, respectively. Additionally, a pan labeled as caramel sauce was found with an expired date. During an interview, the Food Service Director confirmed that all refrigerated foods should have a written expiration date and that expired foods must be removed and discarded, indicating a lapse in following these procedures.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical records for two residents, leading to deficiencies in care. For Resident #47, who was admitted with diagnoses including psychosis and dementia, the facility did not accurately document the treatment involving steri strips on the resident's right forearm. Although the Treatment Administration Record indicated that the steri strip treatment was completed, an observation revealed no steri strips present, and Nurse #8 admitted to signing off on the treatment without actually performing it, as the wound had healed. For Resident #25, who was admitted with diagnoses including diabetes and nutritional anemia, the facility failed to ensure a complete wound description was documented during the admission assessment and weekly skin checks. The resident had a stage 2 pressure ulcer on the coccyx, noted in the hospital discharge summary and nursing notes, but the admission assessment and subsequent skin checks lacked detailed descriptions of the wound. Nurse #1, who completed the assessments, acknowledged the omission and expressed difficulty recalling the wound's appearance due to the time elapsed since admission. Interviews with nursing staff, including the Director of Nursing, highlighted the importance of completing the description section in skin assessments, which was not consistently done. The MDS Nurse also noted that skin assessments were not always accurately completed, impacting the review process for MDS completion. These documentation failures indicate a lack of adherence to the facility's policies on skin audits and pressure ulcer prevention, which require detailed assessments and documentation to ensure proper care and monitoring of residents' skin conditions.
Facility Fails to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the shower rooms of two resident units, as observed during a survey. On one unit, the shower room had dirty tile grout, missing floor tiles around the drain, and a missing drain cover, which was replaced with a metal mesh sink strainer. Additionally, there were several dead and live small winged insects present in the shower room. On the other unit, the shower room also had dark colored stains in the grout on the tiled shower walls. Interviews with facility staff confirmed the deficiencies. The Regional Maintenance Director acknowledged the need for repairs to the grout, drain cover, and tiles in the affected shower room. The Director of Nurses (DON) also stated that the shower rooms should be kept clean, and the tiles and drain cover should be replaced, with the insects removed. These observations and interviews indicate a failure to uphold the facility's policy of providing a safe, clean, comfortable, and homelike environment for residents.
Facility Fails to Support Resident's Right to Self-Determination in Smoking Policy
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by permanently revoking their smoking privileges. The resident, who was admitted with conditions including post-traumatic stress disorder, anxiety disorder, opioid dependence, and hemiplegia, had a care plan that allowed smoking under supervision during designated times. Despite this, the facility revoked the resident's smoking privileges after they were found with a vape pen in their bed, following previous incidents of possessing smoking paraphernalia. The facility's smoking policy required residents to smoke only under staff supervision and prohibited possession of smoking materials. The resident's privileges were initially suspended after two incidents of possessing paraphernalia, and permanently revoked after a third incident. Despite the resident's repeated requests to resume smoking, the facility maintained the revocation, citing non-compliance with the smoking policy. Interviews with facility staff confirmed the resident's ongoing requests to participate in supervised smoking times.
Resident Restrained During Vape Pen Confiscation
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint, as required by their policy, which led to a deficiency. The incident involved a resident who was alert, oriented, and able to make their needs known. The resident had a history of post-traumatic stress disorder, anxiety disorder, opioid dependence, major depressive disorder, and other conditions. On the morning of the incident, Nurse #1, along with CNA #1 and CNA #2, used physical force to confiscate a vape pen from the resident, which was hidden under their clothing. The facility's policy defines restraint as any manual method or device that restricts a resident's freedom of movement and is not easily removed by the resident. The incident was reported by the resident, who claimed that the staff attacked them in bed while trying to take the vape pen. The facility's internal investigation and a report to the Disabled Persons Protection Commission confirmed that the staff held the resident down to remove the vape pen. Interviews with the involved staff revealed that Nurse #1 enlisted the help of CNA #1 and CNA #2 to assist in taking the vape pen, during which the CNAs held the resident's hands to allow Nurse #1 to retrieve the item. The actions of the staff were deemed overly aggressive, leading to the deficiency finding.
Failure to Report Alleged Resident Assault Promptly
Penalty
Summary
The facility failed to adhere to its Abuse Prohibition Policy when a cognitively intact resident alleged that they were assaulted by staff members during an incident involving the confiscation of a vape pen. The incident occurred early in the morning, and the resident reported the alleged assault to a Certified Nurse Aide (CNA), who then informed a nurse. However, the nurse did not immediately report the allegation to the facility's Administrator as required by the policy. Consequently, the Administrator only became aware of the situation when police officers arrived at the facility in response to the resident's call, more than five hours after the incident. The resident involved had a complex medical history, including post-traumatic stress disorder, anxiety disorder, opioid dependence, major depressive disorder, and other conditions. The resident was non-ambulatory, used a wheelchair, and had intact cognitive patterns. The staff members involved in the incident included two CNAs and a nurse, who admitted to confiscating a vape pen from the resident's incontinence brief. Despite being informed of the resident's intention to report the alleged assault to the police, the nurse failed to notify the Administrator promptly, leading to a delay in addressing the resident's allegations.
Verbal Altercation Between CNA and Resident
Penalty
Summary
The Facility failed to ensure staff treated a severely cognitively impaired resident with dignity and respect. The incident involved a verbal altercation between a Certified Nurse Aide (CNA) and the resident, during which profane language was used. The resident, who had severe cognitive impairment due to conditions such as stroke, schizoaffective disorder, and paranoid personality disorder, was admitted to the Facility in October 2022. On the morning of 04/29/24, the resident was heard yelling profanities at CNA #1, who responded with similar profane language. This was witnessed by two nurses who reported the incident. The Facility's policy on Resident Rights, revised in December 2021, mandates that residents be treated with respect and dignity. Despite this, CNA #1 engaged in a verbal altercation with the resident, which was corroborated by multiple staff members through written witness statements. The Director of Nursing (DON) and the Administrator were informed of the incident, and following an internal investigation, CNA #1 was terminated based on the testimonies of the witnesses.
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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