Carleton-willard Village Retirement & Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Bedford, Massachusetts.
- Location
- 100 Old Billerica Road, Bedford, Massachusetts 01730
- CMS Provider Number
- 225273
- Inspections on file
- 29
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Carleton-willard Village Retirement & Nursing Ctr during CMS and state inspections, most recent first.
A CNA transferred a resident requiring two-person assistance with a mechanical sling lift alone, resulting in a fall. The CNA did not report the incident or the resident's injuries to nursing staff, instead returning the resident to bed and leaving them unassessed for over two hours. The resident, who had multiple comorbidities, was later found to have sustained serious injuries including fractures and head trauma.
A CNA transferred a resident with significant mobility and neurological conditions using a mechanical sling lift without the required second staff member, contrary to the care plan and facility policy. During the transfer, the resident fell from the lift and sustained multiple serious injuries, including rib and scapula fractures, subdural bleeds, and a pneumothorax.
A resident with multiple complex diagnoses who required two-person assistance for mechanical lift transfers was transferred by a CNA without a second staff member, contrary to facility policy. During the transfer, the sling detached, causing the resident to fall and sustain multiple serious injuries, including fractures and head trauma. The CNA did not seek help or immediately report the incident, despite adequate staffing being present.
The facility failed to ensure medications were labeled and dated once opened, as per manufacturer's guidelines, across three medication carts. Observations revealed several medications, including Pro-Stat Liquid Protein and fluticasone nasal spray, were opened and undated, making it impossible to determine expiration dates. Interviews with nursing staff and the DON confirmed the requirement for medications to be dated when opened and removed if undated.
A resident with significant visual impairments did not receive the necessary care as outlined in their care plan, which included the use of covered cups for hot beverages and assistance with cutting up food. Observations showed the resident was given uncovered mugs and uncut food, leading to difficulties in eating. Staff interviews revealed a lack of awareness of the care plan requirements, resulting in repeated failures to provide the necessary assistance.
A resident at high risk for falls, with conditions like orthostatic hypotension and legal blindness, experienced two falls resulting in injuries due to the facility's failure to implement and monitor required bed and chair alarms. Despite the care plan's directives, alarms were not consistently used, leading to a head laceration and a nasal fracture.
A resident at high risk for falls, with a history of orthostatic hypotension and other conditions, experienced two falls resulting in injuries due to the facility's failure to implement necessary monitoring devices and provide adequate supervision. Despite being assessed as high risk, the resident did not have bed and chair alarms in place, leading to falls that caused a head laceration and a nasal bone fracture.
A resident with a history of subdural hematoma was found on the floor after an unwitnessed fall. Two CNAs moved the resident to the bed without a nurse's assessment, violating facility policy. The incident was not properly communicated to the nurse, leading to a delay in initiating required neurological assessments.
Failure to Follow Mechanical Lift Transfer Protocol and Timely Reporting of Resident Fall
Penalty
Summary
A certified nurse aide (CNA) transferred a resident who required two-person assistance with a mechanical sling lift by herself, contrary to the facility's policy and the resident's care plan. During the transfer, the resident fell from the lift onto the floor. The CNA did not immediately report the fall to nursing staff, nor did she wait for a nurse to assess the resident before moving them. Instead, she physically lifted the resident from the floor and placed them back in bed without notifying anyone of the incident. After the resident was returned to bed, the CNA still did not inform nursing staff about the fall or the presence of blood on the resident's head. The resident remained in bed for over two and a half hours, during which time he was found to be bleeding from a head wound and was complaining of severe pain. The incident was only discovered when a family member noticed blood during a video call and alerted staff, prompting further assessment and eventual transfer to the hospital. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was subsequently found to have sustained multiple serious injuries, including several fractured ribs, a fractured scapula, spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. The CNA admitted to being aware of the facility's policies regarding mechanical lift transfers and the requirement to report falls but failed to follow them, resulting in a significant delay in care and assessment.
Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident using a mechanical sling lift without the required assistance of a second staff member, as mandated by both the resident's care plan and facility policy. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was care planned to require two staff for all mechanical lift transfers. Despite being aware of this requirement and having received relevant training, the CNA proceeded alone with the transfer. During the transfer, the upper left hook on the sling became disconnected while the resident was suspended approximately four feet above the floor, resulting in the resident falling directly to the ground. The incident was not witnessed by other staff, and the CNA did not request assistance prior to or during the transfer, despite being reminded by a nurse earlier that two staff were needed for such transfers. Other staff on the unit were available at the time, and the staffing schedule confirmed adequate personnel were present. As a result of the fall, the resident sustained multiple serious injuries, including bilateral subdural bleeds, several rib fractures (some with significant displacement and flail segments), a comminuted and displaced scapula fracture, spinal fractures, a pneumothorax, a hemothorax, and a head laceration. The resident was transferred to the hospital for evaluation and treatment before returning to the facility. The failure to follow the care plan and facility policy directly led to the resident's injuries.
Failure to Provide Required Staff Assistance During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident using a mechanical sling lift without the required assistance of a second staff member, as mandated by facility policy. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was care planned to require two staff for all mechanical lift transfers. Despite being aware of this requirement and having received training, the CNA proceeded alone, citing short staffing as the reason for not seeking help. During the transfer, the upper left clip of the sling detached from the lift, causing the resident to fall approximately four feet to the floor. The resident sustained multiple serious injuries, including bilateral subdural bleeds, several rib fractures (some with significant displacement and flail segments), a comminuted and displaced scapula fracture, spinal fractures, a pneumothorax, a hemothorax, and a head laceration. The resident was subsequently transferred to the hospital for evaluation and treatment. Interviews and record reviews confirmed that the CNA was aware of both the resident's needs and facility policy but did not request assistance. Other staff members, including a nurse and another CNA, were present on the unit and available to assist. The staffing schedule indicated adequate staffing levels at the time of the incident. The incident was not immediately reported to nursing staff, and the resident was not assessed by a nurse until later, after signs of injury were observed.
Failure to Label and Date Medications
Penalty
Summary
The facility failed to ensure that medications were labeled and dated once opened, as per the manufacturer's guidelines, across three medication carts. During observations, several medications were found opened and undated, making it impossible to determine their expiration dates. Specifically, a bottle of Pro-Stat Liquid Protein, fluticasone nasal spray, atropine ophthalmic eye drops, and brinzolamide suspension were all found opened and undated. The manufacturer's instructions for these medications require them to be discarded after a certain period post-opening, which could not be verified due to the lack of dating. Interviews with nursing staff confirmed that medications should be dated when opened and that undated medications should be removed from the medication cart. The Director of Nursing also acknowledged that medications must be dated and labeled appropriately when opened, according to the manufacturer's instructions, and that expired medications must be removed. This deficiency indicates a failure in adhering to the facility's policy on the storage of medications, which mandates that medications and biologicals be stored safely, securely, and properly following the manufacturer's recommendations.
Failure to Implement Comprehensive Care Plan for Visually Impaired Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with significant visual impairments, including glaucoma and macular degeneration, leading to moderate cognitive impairment. The care plan specified the need for covered cups for hot beverages and assistance with cutting up food due to the resident's inability to see well enough to manage these tasks independently. However, observations revealed that the resident was consistently provided with uncovered mugs of tea, which were not in accordance with the care plan, and the meal slips did not indicate the need for covered cups. Additionally, the resident's care plan required that food be cut up to accommodate their visual impairment, but this was not consistently done. The resident was observed struggling to eat uncut food items, such as runny fried eggs and sandwiches, which were not prepared according to the specified cut-up diet. Interviews with staff, including CNAs and the Dietitian, confirmed that they were unaware of the specific requirements outlined in the resident's care plan, leading to repeated failures in providing the necessary assistance. The lack of adherence to the care plan was further highlighted during interviews with the Nurse Unit Manager and the Director of Nursing, who acknowledged that the interventions specified in the care plan, such as providing covered cups and cutting up food, should have been implemented. The oversight in following the care plan resulted in the resident experiencing difficulties with eating and increased the risk of spillage and potential harm from hot beverages.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and follow the interventions identified in the care plan for a resident assessed as high risk for falls. The resident, who had multiple diagnoses including orthostatic hypotension and was legally blind, was supposed to have bed and chair alarms as part of their fall risk care plan. However, there was no documentation indicating that these alarms were in place or monitored by staff, leading to two falls within 24 hours, both resulting in injuries. The first fall occurred when the resident was found on the floor in their room with a head laceration, requiring hospital treatment. Interviews with staff revealed that no alarms were in place at the time of the fall, despite the care plan's requirements. The resident was returned to the facility with bed and chair alarms implemented by a nurse, but the alarms were not consistently used or monitored by staff. The second fall happened when a CNA left the resident unattended in the bathroom without an alarm. The resident fell, sustaining a nasal fracture and a hematoma. Staff interviews confirmed that the alarms were not in place during this incident, and the Director of Nurses acknowledged that alarms should have been implemented and residents should not be left alone without them.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure the safety of a resident who was at high risk for falls, resulting in two separate incidents where the resident sustained injuries. The resident, who had a history of orthostatic hypotension, chronic atrial fibrillation, stroke, macular degeneration, and was legally blind, was assessed as being at high risk for falls. Despite this assessment, the facility did not implement the necessary monitoring devices, such as bed and chair alarms, as indicated in the resident's care plan. This lack of implementation was confirmed by multiple staff members who reported that the alarms were not in place at the time of the incidents. On the first occasion, the resident fell in their room and sustained a laceration to the head, requiring hospital treatment. The incident occurred because the resident was left unattended without the necessary alarms in place. Following this fall, bed and chair alarms were implemented; however, the resident experienced a second fall the following day. During this incident, a CNA left the resident unattended in the bathroom without reactivating the alarm, leading to another fall where the resident sustained a nasal bone fracture and a large forehead hematoma. Interviews with the nursing staff and CNAs revealed a lack of adherence to the facility's fall prevention protocols and care plan requirements. The Director of Nursing acknowledged that alarms should have been implemented as per the care plan and that residents with such alarms should not be left alone without them. The failure to provide adequate supervision and safety devices directly contributed to the resident's falls and subsequent injuries.
Failure to Follow Protocol After Unwitnessed Fall
Penalty
Summary
The facility failed to provide quality care consistent with professional standards for a resident with a history of subdural hematoma. On the specified date, two CNAs found the resident on the floor after an unwitnessed fall. Contrary to the facility's policy, they moved the resident to the bed before a licensed nurse could assess them for potential injuries. This action led to a failure in measuring and documenting the resident's neurological signs as required by the facility's policy for unwitnessed falls. The incident was compounded by a lack of communication and documentation. CNA #5 reported a skin tear to Nurse #3 but did not mention the fall. Nurse #3 did not inquire further about the cause of the skin tear or collect statements from other staff. It was only two days later that the resident informed Unit Manager #1 about the fall. This delay resulted in the nursing staff not initiating the necessary neurological assessments following the unwitnessed fall, as confirmed by the Director of Nurses.
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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