Casa De Ramana Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Framingham, Massachusetts.
- Location
- 485 Franklin Street, Framingham, Massachusetts 01702
- CMS Provider Number
- 225179
- Inspections on file
- 20
- Latest survey
- December 9, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Casa De Ramana Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide readily accessible grievance forms for residents, affecting seven out of 13 residents during a Resident Council meeting. Although policy stated forms should be available on each floor, they were instead kept in a file cabinet behind the nurses' station, requiring residents to request them from staff. This hindered residents' ability to file complaints anonymously, as acknowledged by the Administrator.
A facility failed to accurately complete a Level I PASARR for a resident with Bipolar Disorder, leading to the omission of a necessary Level II evaluation. The resident had a history of emergency psychiatric services, but the screening incorrectly indicated no mental illness or recent psychiatric hospitalization. The facility's policy requires a Level II evaluation for suspected serious mental illness, which was not conducted.
A resident with muscle weakness and cognitive impairments was not assisted with ambulation after being discontinued from PT services due to insurance issues. Despite a care plan indicating the need for staff assistance with a rolling walker, facility staff failed to provide the necessary support, as confirmed by documentation and staff interviews.
A resident with significant medical conditions and a left-hand contracture was not provided with necessary personal hygiene assistance, resulting in untrimmed and dirty fingernails, including a potential fungal infection. Despite the resident's need for partial to moderate assistance, facility staff failed to ensure regular nail care, and there was a lack of communication and awareness among staff regarding the resident's needs.
A facility failed to complete the required MDS entry tracking record for a resident readmitted after a hospital discharge. The resident, diagnosed with Striatonigral Degeneration and Adult Failure to Thrive, was discharged with return anticipated but lacked an entry tracking record upon reentry. The MDS Coordinator admitted the oversight, noting the absence of a specific policy for MDS assessments, relying instead on the RAI manual.
A facility failed to accurately code the MDS assessment for a resident, leading to a misrepresentation of limb restraint usage. The resident, with conditions like hemiplegia and hydrocephalus, used a custom wheelchair with bilateral leg straps as a positioning device. The MDS assessment incorrectly indicated restraint use in bed, while observations showed no restraints in bed, and the MDS nurse confirmed the error.
A resident with moderate cognitive impairment was improperly restrained in a tilt-back wheelchair by two CNAs using a blanket tied behind the chair to prevent disrobing. This restraint, intended to preserve dignity, was left in place for at least three hours until discovered by another staff member. The facility's policy on physical restraints was not followed, as the restraint was used for staff convenience rather than the resident's safety.
A resident with moderate cognitive impairment was left unattended and secured in a wheelchair for several hours after a CNA tied a blanket around them to prevent disrobing. Despite witnessing the incident, another CNA did not report it, and the nurse on duty was unaware. The situation was discovered by an OT, revealing a failure to follow the facility's abuse prevention policy.
Grievance Forms Not Readily Available to Residents
Penalty
Summary
The facility failed to ensure that grievance or complaint forms were readily available to residents during their stay, affecting seven out of 13 residents who attended a Resident Council group meeting. The facility's policy indicated that residents should have access to these forms on every floor, located at bulletin board areas and near elevators. However, during a tour and interviews conducted by the surveyor, it was observed that the forms were not available in the designated wall-mounted folders on any of the three nursing units. Instead, the forms were kept in a file cabinet behind the nurses' station, requiring residents to request them from nursing staff. During a group meeting, several residents expressed concerns about the unavailability of grievance forms, stating that they had to ask nursing staff for the forms to file a complaint. The facility's Administrator acknowledged that the forms should have been readily accessible on each floor to allow residents to file complaints anonymously, but they were not. This lack of accessibility to grievance forms hindered residents' ability to voice their concerns without involving staff, contrary to the facility's stated policies.
Failure to Complete Accurate PASARR Screening
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is necessary to determine if a resident has an intellectual or developmental disability and/or serious mental illness requiring further evaluation. Specifically, the facility did not correctly document that the resident had a diagnosis of Bipolar Disorder and had received emergency psychiatric services within the last two years. This oversight resulted in the failure to conduct a required Level II PASARR Evaluation. The resident was admitted with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. Despite this, the PASARR Level I Screening inaccurately indicated that the resident did not have a documented mental illness or require psychiatric hospitalization in the past two years. The facility's policy mandates that individuals suspected of having a serious mental illness be referred for a Level II evaluation, which was not done in this case. The social worker acknowledged the error, noting that a new Level I PASARR should have been completed and a Level II evaluation requested.
Failure to Assist Resident with Ambulation Post-PT Discontinuation
Penalty
Summary
The facility failed to maintain or improve the functional mobility of a resident who was discontinued from Physical Therapy (PT) services due to a lack of insurance coverage. The resident, who was admitted with diagnoses including muscle weakness, Wernicke's Encephalopathy, Metabolic Encephalopathy, and Cognitive Communication Deficit, required assistance with ambulation. Despite the care plan indicating that the resident could ambulate with the assistance of one staff member and a rolling walker, the facility staff did not provide the necessary assistance after PT services were discontinued. Observations and interviews revealed that the resident was not assisted with ambulation by the staff, as confirmed by the Certified Nurses Aide (CNA) Clinical Flow Sheet Documentation, which showed no ambulation in October and November 2024. The Rehabilitation Director and the Director of Nursing (DON) were unaware that the resident had not been assisted with ambulation, and the CNAs did not understand the resident's plan of care. This lack of action led to a deficiency in providing adequate care and services to maintain the resident's ability to perform activities of daily living.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required partial to moderate assistance with personal hygiene. The resident, who was cognitively intact and had a history of significant medical conditions including hemiplegia and hemiparesis, was observed with untrimmed and dirty fingernails, including a potential fungal infection on one nail. Despite the resident's inability to independently manage personal hygiene due to a left-hand contracture, the facility staff did not ensure regular cleaning and trimming of the resident's nails, as was required by the facility's ADL Support Guideline. Interviews with the nursing and rehabilitation staff revealed a lack of awareness and communication regarding the resident's nail care needs. The nurse on duty was unaware of the potential fungal infection and the condition of the resident's nails, while the rehabilitation staff did not recall reporting the issue to nursing despite observing the need for nail care. The Director of Nursing acknowledged that nail trimming and cleaning should be performed as needed and during weekly skin inspections, but there was no evidence that the resident had refused such care. This oversight in providing essential personal hygiene assistance contributed to the deficiency identified by the surveyors.
Failure to Complete MDS Entry Tracking Record for Readmitted Resident
Penalty
Summary
The facility failed to complete the required Minimum Data Set (MDS) entry tracking record for a resident who was readmitted to the facility after being discharged to an acute care hospital with the expectation of return. The Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual mandates that an entry tracking record must be completed every time a resident is admitted or readmitted to a nursing home. This record must be completed within 7 days after the admission or reentry and submitted no later than the 14th calendar day after the entry. However, for this resident, no entry tracking record was found in their clinical record following their readmission. The resident in question was initially admitted to the facility with diagnoses including Striatonigral Degeneration and Adult Failure to Thrive. They were discharged to the hospital and subsequently readmitted to the facility three days later. Despite the requirement, the facility did not complete the entry tracking record upon the resident's return. During an interview, the MDS Coordinator acknowledged that the entry tracking record should have been completed but was not. The facility lacked a specific policy and procedure for the completion of MDS assessments and tracking, relying instead on the RAI manual as a guide.
Inaccurate MDS Coding for Limb Restraint Usage
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded for a resident, leading to a deficiency in the documentation of limb restraint usage. Specifically, the MDS assessment for a resident did not accurately reflect the use of limb restraints while the resident was in their wheelchair and out of bed, but incorrectly indicated the use of restraints while in bed. This discrepancy was identified during a survey when the resident was observed without limb restraints while in bed, contradicting the MDS assessment. The resident in question was admitted with diagnoses including hemiplegia, hydrocephalus, and left foot drop, and utilized a custom wheelchair with bilateral leg straps as a positioning device. The care plan and physician's orders specified the use of these straps to prevent falls and facilitate participation in the community, with instructions to release and reposition the straps regularly. However, the MDS assessment failed to accurately document this usage, leading to a misrepresentation of the resident's restraint status during the observation period. The MDS nurse acknowledged the error, confirming that the resident did not use limb restraints while in bed.
Resident Restrained with Blanket for Staff Convenience
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for staff convenience. On a specific date, during the overnight shift, two CNAs transferred a moderately cognitively impaired resident into a tilt-back wheelchair. One of the CNAs placed a blanket across the resident's torso and lap area and tied it behind the wheelchair, securing it snugly in place. This action was taken to prevent the resident from disrobing, a behavior noted in the resident's history. The resident was left in this restrained position for at least three hours until discovered by a staff member on the following shift. The facility's policy on the use of physical restraints indicates that restraints should only be used for the safety and well-being of residents and only after other alternatives have been unsuccessful. The policy defines a physical restraint as any method or device that restricts a resident's freedom of movement and cannot be easily removed by the resident. In this case, the blanket tied behind the wheelchair met the criteria for a physical restraint, as it restricted the resident's movement and was not easily removable by the resident. Interviews with staff revealed that CNA #1 tied the blanket to preserve the resident's dignity, as the resident frequently disrobed. CNA #2 witnessed the action but did not report it to the nurse on duty. The nurse, who was unaware of the restraint, had been in the room after the incident but did not notice the blanket was tied. The incident was only discovered when an occupational therapist attempted to reposition the resident's wheelchair. The facility's investigation concluded that the action was technically a restraint, despite the CNA's intention to maintain the resident's dignity.
Failure to Report and Address Resident Restraint
Penalty
Summary
The facility failed to implement and follow its Abuse Policy for a resident with moderate cognitive impairment. On the morning of August 14, 2024, a Certified Nurse Aide (CNA) placed a blanket across the resident's lap and torso, securing it by tying it behind the wheelchair. This action was taken to prevent the resident from disrobing, as the resident had a behavior of frequent disrobing. However, this act resulted in the resident being left unattended and secured in the wheelchair for at least three hours until discovered by another staff member. The facility's policy mandates that any staff observing suspected abuse must remove the resident from danger immediately and report the incident to a licensed nurse. Despite witnessing the incident, a second CNA did not report it to the nurse or administration. The nurse on duty was unaware of the situation as it was not communicated to her by either CNA. The incident was only discovered when an Occupational Therapist attempted to reposition the resident's wheelchair and found the blanket tied tightly, preventing the resident from self-rising. Interviews with the involved staff revealed that the CNA who tied the blanket believed it was the best way to maintain the resident's dignity. However, the second CNA, who questioned the action, failed to report it. The Director of Nurses confirmed that the incident was not reported to the administration as required by the facility's policy, highlighting a breakdown in communication and adherence to the abuse prevention guidelines.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
