Catholic Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 2446 Highland Avenue, Fall River, Massachusetts 02720
- CMS Provider Number
- 225448
- Inspections on file
- 27
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Catholic Memorial Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls, who required continual supervision during ambulation, was able to leave their unit unsupervised, exit through the main entrance, and fall, resulting in a pelvic fracture. Staff interviews confirmed that although the need for supervision was documented and known, lapses in supervision occurred when staff attended to other residents, leading to the incident.
A resident with severe cognitive impairment and a high risk for falls and elopement was left unsupervised due to lapses in staff coverage. During this period, the resident exited the unit undetected, reached the main entrance, and fell, resulting in a pelvic fracture. Staff interviews confirmed the resident required continual supervision, which was not maintained at the time of the incident.
Staff were observed standing and walking around while feeding multiple residents, rather than sitting and providing individualized meal assistance as required by facility policy. This practice failed to honor residents' rights to dignity and respect during meals, as confirmed by staff interviews and observations across several units.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene when moving between rooms of residents on precautions, not using required PPE during high-contact care for a resident with surgical wounds, and not offering or performing hand hygiene for residents before meals. Additionally, medication carts were found dirty, and a nurse was seen touching medication with a bare finger, all contrary to facility policy.
Staff conducted a cognitive assessment for a resident with moderate impairment in a public corridor, allowing others to overhear sensitive information. Additionally, a feeding assistance list displaying the names and room numbers of multiple residents was posted on a dining room door, making protected health information visible to residents, staff, and visitors. Both actions violated HIPAA and the facility's privacy policies.
A resident with dementia and a history of falls had a care plan requiring the call light to be within reach at all times, along with reminders to use it for assistance. Surveyor observations on multiple occasions found the call light cord out of the resident's reach while in bed and in a reclining chair. Staff interviews confirmed the resident could ambulate and knew how to use the call light, and that keeping it within reach was a care plan intervention, but this was not consistently done.
Surveyors found that two residents' medications were not properly labeled or securely stored: an unlabeled pill was discovered in a medication cart by an LPN who could not identify it, and two tubes of topical antibiotics were repeatedly left unsecured in a resident's room. Facility staff confirmed these practices were not in accordance with policy.
A resident with bilateral hand contractures was not provided with recommended adaptive eating equipment, such as built-up utensil handles and handled cups, during meals. Despite OT recommendations and care plan interventions, the resident was observed struggling to use standard disposable utensils and cups, and staff did not effectively communicate or implement the necessary adaptations.
Surveyors observed that opened containers of thickened liquids in multiple kitchenettes were not dated as required, making it impossible for staff to determine when to discard them according to manufacturer and FDA Food Code guidelines. Staff interviews confirmed the absence of a system to ensure proper date marking of opened food and drink items.
A resident's medical record did not accurately reflect the activation status of their health care proxy (HCP). Although facility records such as the MDS, physician's orders, and care plan indicated the HCP was activated, both the hospital discharge summary and multiple provider notes stated otherwise. A unit manager later confirmed the HCP activation order may have been entered in error, resulting in incomplete and inaccurate documentation.
Failure to Consistently Implement Supervision Interventions for High-Risk Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, epilepsy, and anxiety was identified as being at risk for falls and elopement, requiring continual supervision during ambulation according to their care plan and resident profile. On the evening in question, the resident was able to leave their assigned unit undetected by staff, walk to the main entrance, open the door, and subsequently fall, resulting in a pelvic fracture. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, addressing all identified needs. Multiple staff interviews revealed that although the resident's need for continual supervision was documented and known, supervision was not consistently maintained. Certified Nurse Aides (CNAs) on duty were aware of the resident's fall risk and supervision requirements, but supervision was interrupted when staff attended to other residents. There was a lack of clear handoff or assurance that the resident remained in the line of sight, leading to the resident leaving the unit without staff knowledge. The Director of Nursing and other staff confirmed that the resident should have been under continual supervision and that staff should always know the resident's whereabouts. The failure to maintain required supervision directly resulted in the resident's unsupervised ambulation, exit from the unit, and subsequent fall and injury. The deficiency was attributed to staff not consistently implementing and following the care plan interventions as outlined for the resident.
Failure to Provide Required Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A resident with diagnoses including dementia, epilepsy, and anxiety, and with severe cognitive impairment, was identified as being at high risk for falls and elopement. The resident required continual supervision during ambulation due to poor safety awareness and a history of exit-seeking behaviors. The care plan and facility policy both specified the need for ongoing staff supervision and interventions to maintain the resident's safety. On the evening of the incident, the resident was initially supervised by a CNA in the dining room, but the CNA had to leave to care for another resident and asked a colleague to supervise the resident. The second CNA, who was familiar with the resident's needs, also had to leave to answer another call light and assumed the resident would be supervised by another staff member. During this lapse in supervision, the resident left the unit undetected, walked to the facility's main entrance, opened the door, and fell outside. The event was witnessed by the receptionist, who attempted to intervene but was unable to prevent the fall. Following the fall, the resident was found on the front steps with complaints of hip and leg pain and was subsequently transferred to the hospital, where a pelvic fracture was diagnosed. Interviews with staff and the DON confirmed that the resident required continual supervision and that staff were not aware the resident had left the unit. The facility's failure to provide the necessary level of supervision directly resulted in the resident's unsupervised exit and subsequent injury.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were provided meal assistance in a respectful and dignified manner, as required by policy and resident rights. Observations revealed that multiple CNAs were standing while feeding residents who were seated, with one instance where a CNA stood directly in front of a resident, resulting in the resident's head being at the CNA's chest level. Additionally, CNAs were observed walking around the dining room, feeding several residents while standing, and not sitting down to provide individualized attention during meals. The facility's policy specifically states that a tray may not be placed in front of a dependent feeder until someone is ready to sit down and immediately feed them, which was not followed in these instances. Interviews with staff confirmed these practices, with one CNA stating she never sits down in the dining room and prefers to feed residents a mouthful of food before moving on to another resident, then returning to the first. The DON acknowledged that her expectation is for staff to be seated while feeding residents. These actions and inactions resulted in a failure to provide meal assistance in a manner that promotes respect, dignity, and enhancement of residents' quality of life and individuality for six residents across three units.
Infection Control Lapses in Hand Hygiene, PPE Use, and Sanitation
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices, as evidenced by multiple observed lapses in hand hygiene, personal protective equipment (PPE) use, and sanitation procedures. Staff were observed entering and exiting rooms of residents on transmission-based precautions, including isolation and contact plus precautions, without performing required hand hygiene. In one instance, a certified nursing assistant (CNA) handled clean hospital gowns and moved between resident rooms without sanitizing hands, despite signage indicating the need for hand hygiene and PPE. The infection control preventionist confirmed that hand hygiene should be performed when entering and exiting rooms of residents on precautions. In another case, a resident on Enhanced Barrier Precautions due to surgical wounds was provided direct care by a CNA who wore gloves but failed to don a gown during high-contact activities such as incontinence care and repositioning. During wound care for the same resident, a nurse was observed changing gloves multiple times without performing hand hygiene between glove changes. Both the CNA and nurse acknowledged awareness of the required precautions but did not follow them during care. Additional deficiencies were observed during meal service, where staff did not offer or perform hand hygiene for residents before meals, nor did they sanitize their own hands between assisting different residents. Medication carts were found to be dirty, with soiled and sticky drawers, and a nurse was observed touching a resident's medication with her bare finger during preparation. Facility policies reviewed by surveyors outlined the expectations for hand hygiene, PPE use, and sanitation, but these were not consistently followed by staff.
Failure to Protect Resident Privacy and Confidentiality of Health Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information in two specific instances. First, a resident with moderate cognitive impairment was assessed for cognitive status using the Brief Interview of Mental Status (BIMS) in a public corridor, where other residents and staff were present and could overhear the assessment. The MDS nurse conducting the assessment acknowledged that it should have been performed in a private space, such as the resident's room, to protect the resident's privacy and dignity. The Director of Nursing also confirmed that the assessment should not have been conducted in the hallway. Second, a sign titled 'Feeding List for 7-3 and 3-11' containing the first and last names and room numbers of 19 residents was posted on the Unit 6 dining room door. This sign was visible to residents, staff, and visitors during meal times. Staff members reported that the list was used as a reference for feeding assistance and had been posted for over a month. The Unit Manager created and updated the list, and the Administrator confirmed that posting this information publicly was a violation of HIPAA, as it made protected health information visible to unauthorized individuals.
Failure to Implement Fall Risk Intervention: Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to implement a person-centered care plan intervention for a resident with dementia and a history of falls. The care plan required that the call light be kept within the resident's reach at all times, with additional interventions to remind and educate the resident to use the call light for assistance. Despite these documented interventions, multiple observations by the surveyor revealed that the call light cord was not within the resident's reach while the resident was in bed or seated in a reclining chair. The red string attached to the call light box was observed hanging at the foot of the bed or on the bed, out of the resident's immediate reach during several checks throughout the day. Interviews with facility staff confirmed that the resident was able to ambulate with a rolling walker and would attempt to get up independently, and that the resident knew how to use the call light. Staff also acknowledged that the call light should be within the resident's reach as part of the care plan interventions. The medical record indicated that the resident had experienced multiple falls during their stay, and the care plan interventions were specifically designed to address this risk. However, the facility did not consistently ensure that the call light was accessible to the resident as required by the care plan.
Failure to Properly Label and Securely Store Medications
Penalty
Summary
Surveyors identified two deficiencies related to medication labeling and storage. For one resident, a nurse was observed preparing medications and an unlabeled, unidentified white pill was found in a plastic medication cup inside the medication cart. The nurse was unable to identify the medication, its dose, the intended recipient, or when it was to be administered. The nurse speculated that it might belong to the resident and could be a dose of levothyroxine, but was not certain. Both the nurse and the Director of Nurses confirmed that leaving medications unlabeled and stored in the medication cart is prohibited and should not occur under any circumstances. In a separate incident, surveyors observed that two tubes of topical antibiotic ointments (Mupirocin and Bacitracin) belonging to another resident were repeatedly left unsecured in a basin on top of the resident's dresser over several days. The Unit Manager confirmed that these medications should not be stored unsecured in the resident's room. These findings indicate a failure to follow facility policies and accepted professional principles for medication labeling and secure storage.
Failure to Provide Adaptive Eating Equipment for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide adaptive eating equipment as recommended for a resident with bilateral hand contractures. Despite occupational therapy (OT) recommendations for built-up handles on utensils and handled cups to maximize the resident's independence during meals, the resident was observed using standard disposable plastic utensils and cups without adaptations. The care plan indicated the need to follow OT recommendations, but during multiple meal observations, the resident struggled to grip and use the provided utensils and cups, resulting in difficulty eating and drinking independently. Interviews with staff revealed that the foam handles previously used did not fit the plastic utensils currently in use due to ongoing kitchen repairs, and this issue was not communicated to management. The OT had educated at least one CNA about the adaptive equipment but did not ensure the recommendations were documented or communicated to the kitchen for implementation. There was also a lack of clear documentation and follow-through on the OT discharge recommendations, leading to the resident not receiving the necessary adaptive equipment during meals.
Failure to Date and Store Opened Food Items per Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety by not properly dating and storing food items in all three kitchenettes observed. Specifically, surveyors found multiple opened containers of thickened liquids on Unit 6 that were not dated to indicate when they had been opened, despite manufacturer instructions requiring use or disposal within a specified number of days after opening. The lack of date marking made it impossible for staff to determine when the containers should be discarded, as required by both the FDA Food Code and manufacturer guidelines. Interviews with staff confirmed that there was no system in place to ensure opened food and drink items were dated. A CNA acknowledged that opened items should be dated so staff know when to discard them, but was unable to determine when the thickened liquid container had been opened. The Food Service Director also confirmed that items should be dated upon opening and discarded according to manufacturer instructions, indicating a failure in following established food safety protocols.
Inaccurate Documentation of Health Care Proxy Activation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not correctly documenting the activation status of the resident's health care proxy (HCP). The resident, who was admitted with diagnoses including left calf hematoma evacuation, wound debridement, and atrial fibrillation, was assessed as moderately cognitively impaired with a BIMS score of eight out of 15. The facility's records, including the Minimum Data Set (MDS), physician's orders, and care plan, indicated that the resident's HCP was activated. However, review of the outside hospital's discharge summary showed that while the resident had signed advanced directives and a HCP document, there was no indication that the HCP had been invoked at the hospital. Further review of physician and nurse practitioner progress notes consistently documented that the HCP was not activated. During an interview, a unit manager acknowledged that the order indicating HCP activation may have been entered in error. This inconsistency in documentation resulted in the resident's medical record failing to accurately reflect the true status of the HCP activation, contrary to the facility's policy and accepted professional standards.
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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