Carvalho Grove Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 273 Oak Grove Avenue, Fall River, Massachusetts 02723
- CMS Provider Number
- 225453
- Inspections on file
- 18
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Carvalho Grove Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and dependence for transfers required a sit-to-stand mechanical lift with two-person assistance per therapy assessments and facility policy, but the ADL care plan and CNA care card did not specify the required number of staff or clearly reflect the mechanical lift requirement. An agency CNA, despite being informed that two staff were needed and offered help, performed a sit-to-stand lift transfer alone, during which the resident let go of the hand supports, slid from the sling to the floor, and sustained fractures of the distal tibia and fibula. After the injury, the resident returned from the ED with a fiberglass splint and non–weight-bearing orders, yet the care plans and care card inaccurately documented use of a CAM boot with related interventions, even though nursing staff and the DON confirmed the resident had only a fiberglass splint and no CAM boot, and the plans were not updated to reflect the actual splint care needs.
A resident with cerebral palsy, lower extremity weakness, and multiple comorbidities was care planned and documented by therapy to require a Sit/Stand Lift with two staff for all transfers. Facility policy required two staff for all mechanical lift transfers, and CNAs on the unit informed an agency CNA that this resident needed two-person assistance. Despite this, the agency CNA performed a Sit/Stand Lift transfer alone, with no second staff member in the room; during the transfer the resident released the hand supports, slid from the sling to the floor, and sustained fractures of the distal tibia and fibula. The resident reported that transfers had always been done with two staff before this event, and other staff interviews and documentation confirmed that the transfer was done by a single CNA in violation of policy.
A resident with multiple comorbidities and intact cognition sustained a left ankle fracture after sliding from a sit/stand lift and returned from the ED with a short leg splint and non‑weight‑bearing instructions. The care plan and TAR incorrectly identified the device as a CAM boot and included orders to apply skin prep to the left heel and remove the CAM boot to assess skin and for signs of swelling or infection. Licensed nurses on all shifts documented completion of these CAM boot‑related treatments even though the resident never had a CAM boot, only a splint with an Ace wrap. Interviews with the resident, several nurses, and the DON confirmed that staff knew the resident had a splint, not a CAM boot, and one nurse admitted she did not know what a CAM boot was and had not performed the documented treatments, demonstrating inaccurate documentation and failure to follow the actual orthopedic orders.
A resident with multiple chronic conditions, including cerebral palsy, DVT, muscle weakness, and a lumbar compression fracture, was care planned and assessed as dependent on staff for transfers, bed mobility, dressing, personal hygiene, bathing, grooming, toileting, and showers. Review of CNA ADL flow sheets over a two‑month period showed numerous days on all three shifts where all ADL care areas were left blank, despite facility policy requiring documentation of services provided and CNAs’ statements that ADLs must be documented in POC in the EMR by the end of each shift. The DON acknowledged CNA documentation had been an issue and affirmed that daily documentation should not be incomplete or left blank.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care during normal and emergency operations. The assessment lacked details on resident care needs, physical environment, equipment, and cultural factors. It also failed to include contracts with third parties and risk assessments. The Administrator admitted the assessment was incomplete and not specific to the facility's needs.
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) plan, lacking tracking methods, written goals, and regular project evaluations. The Administrator admitted to not maintaining meeting notes or records of past QAPI projects, and there was no current or previous Performance Improvement Project (PIP) in place. The facility could not provide documentation of QAPI minutes or PIPs, indicating a significant deficiency in their quality assurance processes.
A facility failed to protect a resident's privacy by using an unsecured text messaging app to communicate health information. The UM mistakenly believed the platform was encrypted, but it was not. Additionally, residents reported that USPS mail and packages were not delivered on Saturdays, as the receptionist responsible for sorting mail only worked weekdays, causing delays in mail distribution.
The facility did not ensure residents were aware of the grievance process, as nine residents reported not seeing postings or knowing how to file grievances other than verbally informing staff. Grievance forms were not easily visible, and the option for anonymous filing was not communicated. The Administrator acknowledged the lack of postings and resident awareness.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. A resident with end-stage renal disease consumed excess fluids due to staff's lack of awareness of a fluid restriction. Another resident with a urinary catheter did not receive appropriate care, as staff assumed independence. Additionally, care plans for psychotropic medication use were incomplete, and a gastrostomy tube care plan was accidentally canceled. These issues highlight inadequate care planning and communication among staff.
The facility failed to adhere to professional standards in medication administration and fluid management for several residents. A resident received Clonidine despite blood pressure readings below the prescribed parameter, risking hypotension. Two residents with fluid restrictions had inadequate documentation and communication, leading to excessive fluid intake. Additionally, insulin injection sites were not rotated for a diabetic resident, and a prescribed hand splint was not consistently used for another resident, indicating non-compliance with physician orders.
A facility failed to ensure a physician signed and dated all orders for a resident with multiple diagnoses, including diabetes and chronic kidney disease. The facility's policy requires orders to be signed every 30 or 60 days, but the last signed orders were from November 2024. The DON confirmed the non-compliance during an interview.
The facility failed to provide timely physician or NP visits for three residents, resulting in lapses in required oversight. A resident with chronic conditions did not receive visits every 30 days during the first 90 days of admission, with a 61-day gap between visits. Another resident experienced a 372-day gap between physician visits, despite being seen by an NP. A third resident had not been seen for 110 days, violating the 60-day visit requirement. These deficiencies indicate lapses in regulatory compliance for resident care.
A facility's Consultant Pharmacist failed to identify medication irregularities during monthly reviews for two residents. One resident received Ultram for pain levels below prescribed parameters, while another lacked documented rationale for ongoing PRN Xanax use. The pharmacist did not report these issues, assuming prescribers were aware of documentation requirements.
The facility failed to follow food safety standards, with unlabeled and expired food found in the main kitchen and nourishment areas. Beverages and desserts lacked proper labeling, and frozen omelets were improperly stored. Expired yogurts were not disposed of, as confirmed by the FSD.
Two residents were found to be self-administering medications without proper assessments or physician's orders. One resident with herpes viral keratitis was using Prednisolone Ophthalmic Suspension, and another with post-polio syndrome was using Fluticasone Nasal Spray. Both residents had their medications unsecured at their bedside, and facility staff confirmed that necessary evaluations and orders were not completed.
A resident with Alzheimer's and a history of falls did not have their call light within reach, contrary to facility policy and care plan requirements. Observations showed the call light was consistently out of reach, and staff interviews confirmed it should always be accessible.
The facility failed to notify physicians of significant changes in condition for two residents. One resident's STAT chest x-ray results were not communicated, delaying treatment decisions. Another resident exceeded their fluid restriction, but the physician was not informed of the non-compliance. These actions breached facility policies and regulatory standards.
A nurse failed to secure a vial of Lispro Insulin on a medication cart, leaving it unattended and accessible to residents. This action was against the facility's policy, which requires medication carts to be locked and inaccessible when not under direct supervision. The nurse admitted the oversight, and the Unit Manager confirmed the policy requirements.
Two residents in an LTC facility received inadequate pain management, with opioid medications administered outside prescribed parameters. One resident with chronic pain syndrome and rheumatoid arthritis lacked a comprehensive care plan, while another resident received Hydromorphone for pain levels below the prescribed range. Staff interviews confirmed these deficiencies in pain management practices.
A resident with severe cognitive impairment was administered two antibiotics, Augmentin and Bactrim, concurrently without adequate clinical indications. The resident's daughter expressed concerns about a possible infection, leading to the initiation of Augmentin before urinalysis results confirmed a UTI. A physician later prescribed Bactrim, suspecting aspiration pneumonia, but was unaware of the ongoing Augmentin treatment. The facility delayed reviewing chest x-ray results, which showed clear lungs, indicating a lack of communication and oversight in medication administration.
The facility failed to monitor a resident for side effects of an antianxiety medication and did not document a rationale for the continued use of a PRN psychotropic medication for another resident. Despite minimal use and observations of calm behavior, the facility extended the PRN order without proper documentation of necessity or effectiveness, contrary to its policies.
A facility failed to maintain an accurate medical record for a resident admitted in October 2024. Only one progress note was initially available, despite the resident being active and having a hospital leave. The process involved the receptionist receiving and scanning notes into the record, but no additional notes were found. An NP was surprised by the lack of documentation, and later, additional notes were added. The DON acknowledged the issue and suspected a problem with the physician's computer system.
A nurse failed to perform hand hygiene between glove changes during wound care for a resident with a stage 4 pressure ulcer and a G-tube. The nurse admitted to not having hand sanitizer available, and the DON confirmed the expectation for hand hygiene between glove changes.
A resident with severe cognitive impairment was inappropriately treated with dual antibiotics for a UTI, despite not meeting the facility's McGeer criteria. The resident was prescribed Augmentin following a family request and later received Bactrim DS without the attending physician's knowledge of the ongoing treatment. This oversight violated the facility's antibiotic stewardship program, as there was a lack of communication and monitoring of the resident's antibiotic use.
The facility did not ensure that survey results and plans of correction were easily accessible to residents and their representatives. Nine residents were unaware of the availability of these documents, and a surveyor found the survey results binder inaccessible behind the reception desk. The Administrator was not aware of this issue.
The facility did not notify the State agency of a change in the Administrator. The current Administrator began on December 27, 2023, but the last update in the HCFRS was on October 30, 2023. The Director of Operations confirmed the oversight, believing the previous DON had updated the information.
A resident with an activated Health Care Proxy and on hospice care was found fully clothed in a bathtub with cold water running. Despite facility policy, the Health Care Agent was not notified until six hours later by the hospice nurse. The incident was reported to the Director of Nurses and the physician, but the full details were not communicated. Facility staff interviews revealed an expectation for immediate notification, which was not met, leading to a delay in informing the HCA.
A resident with a complex medical history was found in a bathtub with cold water, fully clothed, and visibly shivering. Despite the situation, the nursing staff failed to assess and document the resident's vital signs immediately after the incident, which is against the facility's policies and standard nursing practices. Interviews with staff confirmed the lack of documentation and assessment, indicating a significant oversight in care.
A resident under hospice care was found in a bathtub with cold water running, visibly cold and shivering. The facility failed to notify the hospice agency immediately, as required by policy, resulting in a six-hour delay. Staff interviews revealed a lack of communication and responsibility in reporting the incident.
Failure to Specify Transfer Assistance and Accurately Care Plan Post-Fracture Splint
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized comprehensive care plan that clearly specified transfer assistance needs, including the required number of staff for mechanical lift transfers, for a resident who was dependent on staff for transfers. The resident, admitted with diagnoses including cerebral palsy, lower extremity DVT, muscle weakness, lumbar compression fracture, and other conditions, was cognitively intact and required a sit-to-stand mechanical lift and maximal assistance of two staff for all transfers per occupational therapy assessments. The resident’s ADL care plan and Resident Care Card, which were to guide direct care staff, documented that the resident required physical assistance to dependence with transfers but did not indicate the number of staff required or that a mechanical lift with two staff was needed, despite facility policy requiring two staff for mechanical lift transfers. On the evening of the incident, an agency CNA working his first shift at the facility received report that the resident required a sit-to-stand lift for transfers and acknowledged he knew that such transfers required two staff. Although another CNA on the unit told him that the resident required two-person assistance with the sit-to-stand lift and offered to help, the agency CNA proceeded to transfer the resident alone using the sit-to-stand lift. During this transfer, the resident let go of the hand supports and slid out of the lift sling onto the floor. The resident reported that there had always been two staff present for prior sit-to-stand transfers and that on the day of the fall a single male CNA transferred them without assistance. Nursing staff documented and reported that the resident fell from the sit-to-stand lift during the transfer and complained of left ankle pain. Following the fall, the resident was evaluated in the emergency department and diagnosed with fractures of the distal left tibia and fibula, and a short leg fiberglass splint with an Ace wrap was applied with orders for non-weight-bearing status and to keep the splint on. Subsequent orthopedic consultations directed that the splint remain in place and that the resident remain non-weight-bearing. However, the resident’s updated care plans and Resident Care Card inaccurately documented that the resident had a CAM boot to the left lower extremity when out of bed, with interventions to encourage use of the CAM boot and to check circulation, sensation, motion (CSM) and skin integrity while the boot was on. Multiple nurses, including the DON, confirmed that the resident did not have a CAM boot but instead had a fiberglass splint with an Ace wrap, and staff were unable to locate any CAM boot for the resident. The DON acknowledged that the care plans were not accurate, had not been updated after the orthopedic consults, and should have reflected the fiberglass splint and appropriate interventions, goals, and outcomes related to the fracture and splint care.
Failure to Use Two-Person Assist for Sit/Stand Lift Transfer Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers and adequate supervision for a dependent resident who required a Sit/Stand Lift with two staff assisting for all transfers. Facility policy, revised in May 2025, required that two staff members be utilized for all mechanical lift transfers, including sit-to-stand lifts, and that staff maintain compliance with safe handling and transfer practices. The resident’s care plan, Resident Care Card, and an occupational therapy recertification and updated therapy plan dated 12/29/25 all documented that the resident was dependent for transfers, required a Sit/Stand Lift for all transfers, and needed moderate to maximal assistance of two staff members. The resident, admitted in March 2024, had diagnoses including cerebral palsy, embolism and thrombosis of deep veins of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra. A quarterly MDS showed the resident was cognitively intact (BIMS 15) but dependent on staff for transfers. Therapy staff, including the COTA and OT, confirmed in interviews that prior to the fall the resident had experienced functional decline, had weak lower extremities, and required a Sit/Stand Lift with maximal assistance of two staff members for all transfers. On the evening of 01/01/26, CNA #1, an agency CNA with 18 years of experience, transferred the resident using a Sit/Stand Lift without another staff member present in the room, despite knowing that two staff were required for such transfers and having been informed at shift report that the resident required two-person assistance. During the transfer, the resident let go of the hand supports, slid out of the sling, and fell to the floor, subsequently complaining of left ankle pain. The facility’s HCFRS report and hospital ED documentation indicated the resident sustained fractures of the distal left tibia and fibula and was placed in a short leg fiberglass splint. The resident reported that previously there had always been two staff present during Sit/Stand Lift transfers, and another CNA stated she had offered to assist but was never called. Nursing staff interviews and progress notes corroborated that the fall occurred during a Sit/Stand Lift transfer and that the transfer had been performed by CNA #1 without the assistance of another staff member, while the DON was unable to clearly state the facility’s specific policy for Sit/Stand Lift staffing at the time of the survey.
Failure to Provide Accurate Orthotic Care and Honest Documentation After Ankle Fracture
Penalty
Summary
Nursing staff failed to provide care and services that met professional standards of quality for a resident who sustained a fracture of the distal left tibia and fibula after sliding from a sit/stand lift during a transfer. The resident, who had cerebral palsy, a history of deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a lumbar compression fracture, was cognitively intact but dependent on staff for transfers. Following the fall, the resident was evaluated in the emergency department, where a short leg fiberglass splint was applied to the left lower extremity and the resident was returned to the facility with the splint in place and non‑weight‑bearing instructions. Despite this, the resident’s care plan and Treatment Administration Record (TAR) documented that the resident had a Controlled Ankle Motion (CAM) boot on the left lower extremity when out of bed, with orders to apply skin prep to the left heel each shift and to remove the CAM boot as tolerated to assess skin for breakdown, swelling, or infection. These treatments were signed off as completed by licensed nurses on all shifts from early January through early February, even though the resident was never fitted with and never had a CAM boot. Orthopedic consultations later confirmed that the resident was to keep the splint on the left lower extremity and remain non‑weight‑bearing, and surveyor observation showed the resident wearing only a splint with an Ace wrap, with no CAM boot available. Interviews with the resident and multiple nurses revealed that staff knew the resident had a splint with an Ace wrap, not a CAM boot, and that the splint had not been removed. One nurse admitted she did not know what a CAM boot was, acknowledged that the resident did not have one, and stated she had not applied skin prep to the left heel or removed a CAM boot, despite having signed the TAR indicating those treatments were done. Other nurses and the DON consistently stated that the resident returned from the hospital with a splint, not a CAM boot, and that the TAR and treatment orders were not updated to reflect the actual orthotic device and required nursing care. This resulted in documentation of care and treatments that could not have been performed as ordered, and a failure to systematically assess and implement the correct prescribed medical regimen in accordance with professional standards.
Incomplete CNA ADL Documentation for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident who was dependent on staff for Activities of Daily Living (ADLs). Facility policy on charting and documentation, dated May 2023, required that services provided, progress toward care plan goals, changes in condition, and objective observations, treatments, or services be documented in the resident’s medical record. Resident #1, admitted in March 2024 with diagnoses including cerebral palsy, deep vein thrombosis of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra, had a care plan and MDS indicating dependence on staff for transfers, bed mobility, dressing, personal hygiene, bathing, grooming, toileting, and showers. Review of this resident’s CNA ADL flow sheets for December 1–31, 2025, and January 1–31, 2026, showed multiple instances where documentation for all ADL care areas on all three shifts was left blank. In December, the 7 a.m.–3 p.m. shift had 6 days with blank ADL areas, the 3 p.m.–11 p.m. shift had 17 days with blanks, and the 11 p.m.–7 a.m. shift had 20 days with blanks. In January, the 7 a.m.–3 p.m. shift had 7 days with blanks, the 3 p.m.–11 p.m. shift had 18 days with blanks, and the 11 p.m.–7 a.m. shift had 24 days with blanks. Multiple CNAs stated in interviews that ADL documentation is done in Point of Care (POC) in the EMR and must be completed by the end of each shift. The DON acknowledged that CNA documentation had been an ongoing issue, confirmed that CNAs are expected to document all care provided by the end of every shift, and stated that daily documentation should not be incomplete or left blank.
Facility Fails to Conduct Comprehensive Assessment
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that included the necessary resources to provide both emergency and day-to-day care for the resident population. The review of the Centers for Medicare and Medicaid Services (CMS) memo indicated that the facility assessment should involve active participation from the resident population and consider their care requirements, physical environment, equipment, and any ethnic, cultural, or religious factors affecting care. Additionally, the facility's resources, including buildings, equipment, and agreements with third parties for services during normal and emergency operations, should be assessed. However, the facility's assessment, last updated on 1/28/25, did not include these critical elements. During an interview, the Administrator acknowledged that the facility assessment provided to surveyors was the most updated version but admitted it was missing key elements and was not specific to the facility. The assessment lacked details on the resident population's care needs, the necessary physical environment and equipment, and any ethnic, cultural, or religious factors affecting care. Furthermore, it did not include a list of contracts and agreements with third parties or a facility-based and community-based risk assessment. The Administrator recognized that the assessment should have been more specific to the facility's population and needs.
Deficiency in Quality Assurance Processes
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively identified quality deficient areas and implemented appropriate corrective action plans. Specifically, the facility did not develop or implement a Quality Assurance Performance Improvement (QAPI) plan or a Performance Improvement Project (PIP) that focused on high-risk or problem-prone areas identified through data collection and analysis. The facility's policy outlined a comprehensive approach to QAPI, including the establishment of a data-driven, proactive program to improve quality of care and services. However, the facility did not adhere to these guidelines, as evidenced by the lack of tracking methods, written goals, and regular comparisons of projects. During an interview, the Administrator admitted that while the QAPI committee met regularly, there was no system in place to track the effectiveness of QAPI projects or to determine if they needed re-evaluation. The Administrator also acknowledged that meeting notes and records of past QAPI projects were not maintained until recently, and there was no current or previous PIP in place. At the end of the survey, the facility was unable to provide any additional documentation or evidence of QAPI minutes or PIPs, highlighting a significant deficiency in their quality assurance processes.
Breach of Resident Privacy and Delayed Mail Delivery
Penalty
Summary
The facility failed to protect the personal privacy and confidentiality of Resident #337 by allowing the Unit Manager (UM) to communicate the resident's private health information via an unsecured text messaging application on a personal cell phone. The UM believed the platform was encrypted, but it was not, and the Director of Nursing (DON) confirmed that the resident's physician and nurse practitioner did not use a secure messaging platform. The text message included the resident's full name, change in medical condition, and treatment plan, which should have been communicated through a secure method, such as a phone call. Additionally, the facility did not ensure that United States Postal Service (USPS) mail and packages were promptly delivered to residents within 24 hours of delivery. During a resident group meeting, nine residents reported that mail and packages were not delivered on Saturdays because the receptionist, who is responsible for sorting and distributing mail, only works Monday through Friday. As a result, mail delivered on Saturdays was not distributed until the following Monday, delaying residents' access to their mail.
Facility Fails to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process, as observed during a resident group meeting attended by nine residents from three different units. These residents reported that they had not seen any postings about the grievance process and were unaware of how to file a grievance other than verbally informing a staff member. They were also not informed about the availability of grievance forms or the option to file grievances anonymously. This lack of awareness among residents indicates a failure in the facility's communication and implementation of its grievance policy. During a tour of the facility, the surveyor noted the absence of visible postings about the grievance process on the second-floor unit and found that the grievance forms were not easily accessible or visible due to their placement in a black wire mesh file holder. The sign above the file holder did not mention the availability of grievance forms or the option for anonymous filing. The Administrator, who is the Grievance Officer, acknowledged the oversight and confirmed that there were no postings to inform residents about the grievance process or the availability of forms, and he was unaware that residents did not know they could file grievances anonymously.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. For one resident with end-stage renal disease, the facility did not enforce a prescribed fluid restriction, resulting in the resident consuming more fluids than allowed. Staff, including CNAs and nurses, were unaware of the fluid restriction, and the resident was frequently observed with excess fluids at their bedside. The facility's failure to communicate and implement the care plan led to non-compliance with the resident's medical needs. Another resident with a urinary catheter did not receive appropriate catheter care as outlined in their care plan. The resident was independent in their activities of daily living, and staff assumed the resident was managing their catheter care independently. However, the care plan required staff to provide catheter care every shift, which was not being done. The resident was using alcohol wipes to clean the catheter tubing, which was not appropriate and could contribute to infections. The care plan was not individualized to reflect the resident's independence and actual care needs. Additionally, the facility failed to develop care plans for residents using psychotropic medications, lacking specific targeted behaviors, non-pharmacological interventions, and measurable goals. One resident with a gastrostomy tube did not have a care plan in place after it was accidentally canceled by the dietitian. These oversights indicate a lack of proper care planning and communication among staff, leading to inadequate care for the residents involved.
Failure to Adhere to Professional Standards in Medication and Fluid Management
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering medications and managing fluid restrictions for several residents. For one resident, Clonidine, an antihypertensive drug, was administered despite the systolic blood pressure being below the prescribed parameter of greater than 180, on multiple occasions. This was confirmed by both a nurse and the Director of Nurses (DON), who acknowledged the potential danger of hypotension due to the resident's concurrent use of other antihypertensive medications and dialysis dependency. Two residents with end-stage renal disease and prescribed fluid restrictions were not managed according to their physician's orders. One resident's fluid intake was not accurately documented or communicated to the dietary department, resulting in excessive fluid being provided. The intake and output records were incomplete, and the dietary department was unaware of the fluid restriction. Similarly, another resident's fluid restriction was not consistently followed, with observations of excessive fluid at the bedside and incomplete documentation of fluid intake, indicating a lack of adherence to the prescribed fluid management plan. Additionally, the facility failed to rotate insulin injection sites for a resident with diabetes, as required to prevent complications such as lipohypertrophy. The medical records lacked documentation of injection sites, which was confirmed by the DON and a physician. Furthermore, a resident with a prescribed hand splint for hemiplegia was observed multiple times without the splint in place, and there was no documentation of refusal or inability to tolerate the splint, indicating non-compliance with the physician's orders for splint use.
Physician Order Signing Deficiency
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders for a resident, leading to a deficiency. The facility's policy requires physician orders and progress notes to be signed and dated every 30 days, or every 60 days after the first 90 days of a resident's admission. A resident, admitted in August 2016 with diagnoses including diabetes mellitus, chronic kidney disease, major depression with severe psychotic symptoms, and bipolar disorder, had their last physician-signed orders dated November 2024. No additional orders were signed by the physician after this date. During an interview, the Director of Nursing confirmed that the last signed physician's orders in the medical record were from November 2024, indicating non-compliance with the facility's policy.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents received timely visits from physicians or nurse practitioners as required by regulations. For one resident, the facility did not provide visits every 30 days during the first 90 days of admission. The resident, who was admitted with chronic kidney disease, end-stage renal disease, bipolar disorder, and generalized anxiety, had a gap of 61 days between visits. The medical records clerk and receptionist confirmed that no additional progress notes were available, indicating a lapse in the required oversight. Another resident, admitted in November 2020, experienced a significant lapse in physician visits, with a gap of 372 days between documented visits. Although the resident was seen by a nurse practitioner during this period, the facility did not meet the requirement for alternating visits between a physician and a nurse practitioner every 60 days. The Director of Nursing and the physician acknowledged the oversight and attempted to retrieve missing progress notes from the physician's office. A third resident, admitted in August 2016, had not been seen by a physician or nurse practitioner for 110 days, contrary to the requirement for visits every 60 days after the initial 90-day period. The Director of Nursing confirmed the absence of visit notes in the resident's medical record, indicating a failure to provide the necessary oversight and care. These deficiencies highlight lapses in the facility's adherence to regulatory requirements for resident care and oversight.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The facility's Consultant Pharmacist failed to identify irregularities in medication administration during the monthly Medication Regimen Review (MRR) for two residents. For one resident, the pharmacist did not report the administration of Ultram, a pain medication, outside the prescribed pain level parameters. The resident was admitted with chronic pain syndrome and rheumatoid arthritis, and the medication was administered multiple times for pain levels below the prescribed threshold. Despite reviewing the medication administration records, the pharmacist did not document any recommendations or identify the discrepancy. For another resident, the pharmacist did not identify the lack of documented rationale for the ongoing use of a PRN psychotropic medication, Xanax. The resident, who had diagnoses including chronic kidney disease, bipolar disorder, and generalized anxiety, had been prescribed Xanax on a PRN basis for anxiety. However, there was no documentation supporting the necessity or effectiveness of the medication, nor was there a risk versus benefit rationale provided. The pharmacist assumed that the prescribers were aware of the requirement for documentation and did not review or ensure that the necessary documentation was in place. Interviews with the Consultant Pharmacist and the Director of Nursing revealed that the pharmacist did not consider it part of his role to ensure that prescribers documented the rationale for extending PRN psychotropic medications. The Director of Nursing expected the pharmacist to identify such issues and provide recommendations, but this did not occur. The pharmacist's oversight in both cases led to a failure in identifying and addressing medication irregularities, which were not communicated to the facility leadership as required.
Food Safety Deficiencies in Kitchen and Nourishment Areas
Penalty
Summary
The facility failed to adhere to professional standards of food safety, which could potentially lead to foodborne illness among residents. The surveyor observed multiple instances of improper labeling and dating of food products in the main kitchen's refrigerators. Specifically, trays of poured beverages and desserts were not labeled with the product name, preparation date, or use by date. Additionally, opened containers of thickened beverages were not labeled with the date they were opened or their use by date. The Food Service Director (FSD) confirmed that these items should have been labeled according to the facility's guidelines, which were not followed. Further deficiencies were noted in the storage practices within the walk-in freezer, where a large cardboard box containing frozen omelets was found open and unsealed, exposing the contents to potential contaminants. In the First Floor Unit nourishment kitchenette, several yogurts were found past their manufacturer's expiration date and were not disposed of as required. The FSD acknowledged that dietary staff are responsible for checking food expirations and confirmed that the expired yogurts should have been discarded. These lapses in food safety practices highlight the facility's failure to maintain proper food handling and storage protocols.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for two residents. Resident #58, who was admitted with herpes viral keratitis, was observed with Prednisolone Ophthalmic Suspension on their overbed table and admitted to self-administering the medication nightly. Despite being cognitively intact and independently able to perform activities of daily living, there was no documented assessment or physician's order for self-administration, and the medication was not stored securely. Resident #73, admitted with post-polio syndrome, was observed with Fluticasone Nasal Spray on their overbed table. Although the resident expressed a desire to self-administer the nasal spray, there was no evaluation or physician's order for self-administration. The resident was dependent on staff for activities of daily living, and the medication was not stored securely. Interviews with facility staff, including nurses and the Director of Nursing, confirmed that the necessary assessments, teaching, and physician's orders were not completed for these residents to self-administer their medications. The facility's policies require that residents who wish to self-administer medications must have an assessment, teaching with return demonstration, and a physician's order, none of which were documented for these residents.
Resident Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident had their call light accessible and within reach, which is a requirement for residents to call for assistance. The resident, who was admitted in July 2014, had diagnoses including Alzheimer's disease, a history of falling, and anxiety, and required extensive assistance for activities of daily living due to a severe cognitive deficit. Observations made by the surveyor on multiple occasions revealed that the resident's call light was consistently out of reach, whether the resident was in bed or in a reclining wheelchair. The facility's policy on the resident call system mandates that residents should have the ability to contact staff for assistance from their bedside and from toilet and bathing areas. The resident's comprehensive care plan also specified that the call bell should be within reach while in the room, bathroom, or shower room. Interviews with staff, including CNAs and the Assistant Director of Nursing, confirmed that call lights should be within reach of residents at all times, regardless of their cognitive ability. Despite these policies and care plan interventions, the facility did not ensure compliance, resulting in the deficiency.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician or responsible party of changes in condition for two residents, leading to deficiencies in care. For one resident, the facility did not communicate the results of a STAT chest x-ray to the physician, which was necessary for making a treatment decision. The resident had been started on an antibiotic for a possible urinary tract infection, and a subsequent fever led to the ordering of a chest x-ray and another antibiotic for possible pneumonia. The x-ray results, which showed clear lungs, were not reviewed by the facility staff until two days after they were sent, and there was no documentation indicating that the physician was informed of these results. Another resident, who was on a fluid restriction due to end-stage renal disease, was observed consuming fluids in excess of the prescribed limit. Despite multiple observations of non-compliance with the fluid restriction, there was no documentation that the attending physician group was notified. The resident was seen with various beverages at their bedside, and staff interviews confirmed that the resident was not compliant with the fluid restriction. The facility's policy required that the physician be notified of such non-compliance, but this was not done. The facility's failure to notify the physician of significant changes in the residents' conditions or non-compliance with treatment orders represents a breach of their own policies and regulatory standards. The lack of communication and documentation in these cases highlights deficiencies in the facility's processes for managing resident care and ensuring that physicians are informed of critical information necessary for making treatment decisions.
Unsecured Insulin Vial Left Unattended
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards on one of its units. During a medication administration process, a nurse left a vial of Lispro Insulin unattended on top of a medication cart. This occurred while the nurse was preparing the insulin for a resident with diabetes mellitus. The medication cart was left unlocked and unsupervised, with four residents in the immediate vicinity, which was against the facility's policy. The facility's policies on administering and storing medications clearly state that medication carts must be locked and inaccessible to residents when not under direct supervision. The nurse acknowledged leaving the insulin vial unattended and admitted that it should have been secured in the locked cart. The Unit Manager confirmed that medications must be secured in a locked cart when not directly supervised by the nurse.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. Resident #30, who was admitted with chronic pain syndrome and rheumatoid arthritis, did not receive pain management consistent with professional standards. The resident was prescribed Ultram for severe pain levels between 7-10, but the medication was administered multiple times for pain levels below the prescribed parameters. Additionally, there was no comprehensive person-centered care plan developed to address the resident's pain management needs, which should have included both pharmacological and non-pharmacological interventions. Resident #57, admitted with a history of surgery on the digestive system and constipation, also experienced deficiencies in pain management. The resident was prescribed Hydromorphone for pain levels between 6-10, but the medication was administered six times for pain levels below the prescribed parameters. This administration was not in accordance with the physician's orders, indicating a failure to adhere to prescribed pain management protocols. Interviews with nursing staff, including Nurse #9, Unit Manager #1, and the Director of Nursing, confirmed that both residents received opioid medications outside of the prescribed pain level parameters. The staff acknowledged that pain medications should be administered as prescribed and within the specified pain level range. The lack of a comprehensive care plan for Resident #30 and the inappropriate administration of pain medication for both residents highlight significant deficiencies in the facility's pain management practices.
Concurrent Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication administration, specifically involving the concurrent use of two antibiotics, Augmentin and Bactrim, without adequate indications for their use. The resident, who had severe cognitive impairment and was diagnosed with gastroparesis and diabetes mellitus, was administered Augmentin based on a nurse practitioner's order before the results of a urinalysis confirmed a urinary tract infection. The resident's daughter had expressed concerns about a possible infection, leading to the initiation of the antibiotic treatment. Subsequently, the resident developed a fever, and a physician ordered a chest x-ray and prescribed Bactrim, suspecting aspiration pneumonia due to the resident's vomiting. However, the physician was not informed that the resident was already receiving Augmentin. The chest x-ray results, which showed clear lungs, were not reviewed by the facility staff until more than two days after they were sent, indicating a delay in communication and review of critical diagnostic information. Interviews with facility staff, including the nurse practitioner, physician, infection preventionist, and director of nursing, revealed a lack of communication and oversight in the administration of antibiotics. The infection preventionist noted that the resident did not meet the criteria for a urinary tract infection, and the director of nursing acknowledged that the resident should not have been on two antibiotics simultaneously without clinical indications. This deficiency highlights the need for improved communication and adherence to clinical guidelines in the administration of medications.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not monitor for potential adverse consequences related to the use of an antianxiety medication, Buspirone. The resident, who had diagnoses including major depressive disorder and anxiety, was receiving Buspirone twice daily as per physician's orders. However, there was no documentation indicating that the facility was monitoring for side effects, which was confirmed during an interview with a unit manager. For another resident, the facility did not provide a documented rationale for the ongoing use of a PRN psychotropic benzodiazepine, Xanax. This resident had diagnoses including chronic kidney disease, end-stage renal disease, bipolar disorder, and generalized anxiety. Despite the resident's minimal use of Xanax and observations indicating calm behavior, the facility continued to extend the PRN order without proper documentation of necessity or effectiveness. Interviews with staff, including a nurse practitioner and the director of nurses, revealed that the rationale for the continued use of Xanax was not documented, and the medication was likely unnecessary. The facility's policies on psychotropic medication use and informed consent were not followed, as there was a lack of documentation supporting the necessity and benefit of the medications for the residents. The director of nurses acknowledged that the facility did not meet the standard for extending the psychotropic PRN medication, as the documentation was not resident-specific and did not include a complete rationale for continued use.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain an accurate and up-to-date medical record for a resident who was admitted in October 2024. During an interview, a nurse indicated that all physician and nurse practitioner (NP) progress notes are scanned into the electronic medical record under a miscellaneous tab. However, upon review, only one progress note was available since the resident's admission, dated November 27, 2024. The resident had a paid hospital leave but remained an active resident since admission. Interviews with the medical records clerk and the receptionist revealed that the process involves the receptionist receiving progress notes via email and then scanning them into the resident's record. The receptionist confirmed that no additional notes were available for the resident. An NP expressed surprise at the lack of notes and indicated a need to investigate further. Subsequent review of the medical record showed that additional notes were later added for November 2024, January 2025, and February 2025. The Director of Nurses acknowledged that all documents should have been included in the medical record at the time of the visits and suspected an issue with the physician's computer system.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Nurse #4 during a wound dressing change for Resident #72. The nurse did not perform hand hygiene after removing gloves and before donning new gloves, which is a critical step in preventing healthcare-associated infections. This lapse occurred multiple times during the procedure, including after cleansing the resident's G-tube site and sacral wound, and before applying new dressings and handling the resident's brief and linens. Resident #72, who was admitted to the facility in June 2024, had a stage 4 pressure ulcer in the sacral region and a gastrostomy tube due to dysphagia. The nurse admitted to not having hand sanitizer in the room and acknowledged the oversight when questioned by the surveyor. The Director of Nursing confirmed that staff are expected to perform hand hygiene between each glove change, highlighting a deviation from the facility's infection control policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the inappropriate use of dual antibiotics for a resident who did not meet the criteria for a urinary tract infection (UTI) according to the facility's McGeer criteria. The resident, who had severe cognitive impairment, was treated with two antibiotics, Augmentin and Bactrim DS, despite only exhibiting one symptom and a positive urine culture, which did not fulfill the criteria for a UTI. The facility's policy requires that antibiotic usage be evaluated and practitioners be provided feedback, but this was not adhered to in this case. The resident's medical records indicated that they were started on Augmentin following a family request and a subsequent order from a nurse practitioner, despite the resident not meeting the infection criteria. The resident was later prescribed Bactrim DS by a physician who was unaware that the resident was already receiving Augmentin. This oversight led to the resident receiving two antibiotics simultaneously without proper verification of an infection or a review of the criteria with the clinicians, which violated the facility's antibiotic stewardship initiative. Interviews with the infection preventionist and the attending physician revealed that there was a lack of communication and monitoring regarding the resident's antibiotic treatment. The infection preventionist admitted to missing the review and notification process, which should have been conducted to ensure compliance with the facility's antibiotic stewardship program. The attending physician was not informed of the resident's ongoing treatment with Augmentin when ordering Bactrim DS, highlighting a breakdown in communication and oversight within the facility's infection control practices.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that statements of deficiencies and plans of correction from complaint investigations were prominently and readily accessible to residents, family members, and legal representatives without requiring them to ask to see them. During a resident group meeting, nine residents from the facility's three units reported being unaware of the availability of survey results and their ability to examine them independently. A surveyor's tour of the second-floor units and the lobby area revealed no postings of survey results. Instead, a binder labeled 'survey results' was found on a shelf behind the reception desk, inaccessible due to its location behind the desk and a table. The Administrator was unaware of the binder's location and its inaccessibility to residents and their representatives.
Failure to Notify State of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State agency regarding a change in the facility's Administrator. During an interview, the Administrator stated that he began his role on December 27, 2023. However, a review of the Health Care Facility Reporting System (HCFRS) indicated that the last notification to the State about an Administrator change was on October 30, 2023. Further examination of the HCFRS showed no record of the State Agency being informed of the current Administrator's appointment. The Director of Operations confirmed during an interview that the Administrator's information had not been updated since October 30, 2023, and mentioned that he believed the previous Director of Nursing had updated the information, which was not the case.
Failure to Notify Health Care Agent of Resident Incident
Penalty
Summary
The facility failed to immediately notify the Health Care Agent (HCA) of a resident who was found in a concerning situation. The resident, who had an activated Health Care Proxy and was on hospice care, was discovered lying fully clothed in a bathtub with cold water running and three inches of water surrounding them. Despite the facility's policy requiring prompt notification of significant changes in a resident's condition, the HCA was not informed until approximately six hours later by the hospice nurse. The incident occurred when a Certified Nurse Aide (CNA) found the resident in the bathtub and immediately informed a nurse. The nurse reported the incident to the Director of Nurses and the physician but failed to notify the HCA or the hospice agency. The physician was informed of the incident but was not made aware of the full details, including the resident being fully clothed and in cold water. The hospice nurse, upon learning of the incident later in the day, was the one who eventually notified the HCA. Interviews with facility staff, including the Assistant Director of Nurses (ADON) and the former Director of Nurses (DON), revealed that it was their expectation for nurses to immediately notify the HCA and hospice agency of any incidents. However, this protocol was not followed, resulting in a significant delay in communication with the resident's HCA, who expected to be informed right away. The resident's condition was noted to be concerning when the HCA visited later that day, prompting a request for hospital evaluation.
Failure to Assess and Document Vital Signs After Incident
Penalty
Summary
The facility failed to provide nursing services that met acceptable standards of practice for a resident who was found lying in a bathtub with three inches of cold water while fully clothed. The incident occurred at approximately 6:35 A.M., and the resident was observed to be visibly cold, shivering, and cold to the touch. Despite these observations, there was no documentation to indicate that a set of vital signs was obtained by the nursing staff immediately following the incident, which is inconsistent with the facility's policies on nursing examination, assessment, and documentation. The resident involved had a medical history that included Alzheimer's disease with late onset, psychotic disorder with delusions, muscle weakness, hypertensive heart disease with heart failure, type 2 diabetes mellitus with hyperglycemia, generalized anxiety disorder, and unspecified dementia with psychotic disturbance. The lack of immediate assessment and documentation of vital signs after the incident was a significant oversight, as vital signs are crucial indicators of a resident's health status and are necessary for appropriate medical evaluation and intervention. Interviews with the nursing staff, including Nurse #1 who was responsible for the resident's care at the time, revealed that there was no recollection or documentation of vital signs being taken after the incident. The Assistant Director of Nurses, the Physician, and the former Director of Nurses all expressed that it was their expectation for nurses to obtain and document vital signs as part of the nursing assessment following any incident, highlighting a deviation from standard nursing practice and facility policy.
Failure to Notify Hospice of Resident Incident
Penalty
Summary
The facility failed to ensure immediate communication with the hospice agency regarding a significant incident involving a resident under hospice care. On the morning of August 21, 2024, a resident was found by staff lying fully clothed in a bathtub with cold water running, surrounded by three inches of cold water. The resident was visibly cold, shivering, and cold to the touch. Despite the facility's policy requiring immediate notification of hospice staff in such situations, the hospice agency was not informed until six hours later when the hospice nurse arrived at the facility. The incident report and nurse progress notes lacked documentation of timely communication with the hospice agency. Interviews with facility staff, including nurses and the Assistant Director of Nurses, revealed a breakdown in communication and responsibility. Nurse #1, who discovered the resident, reported the incident to the Director of Nurses and the physician but did not notify the hospice agency. Nurse #3, who took over the resident's care, also failed to report the incident to hospice until the hospice nurse's arrival. The Assistant Director of Nurses and the former Director of Nurses both expressed that it was expected for nurses to immediately notify hospice of any incidents involving residents on hospice care.
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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