Cedarwood Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Massachusetts.
- Location
- 130 Chestnut Street, Franklin, Massachusetts 02038
- CMS Provider Number
- 225461
- Inspections on file
- 20
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cedarwood Gardens during CMS and state inspections, most recent first.
The facility did not submit required direct care staffing data to CMS for an entire quarter, as confirmed by review of policy, PBJ and CASPER reports, and multiple interviews with leadership. This resulted in no staffing data being reported, a one-star staffing rating, and documented gaps in RN and licensed nurse coverage.
A resident with schizophrenia and dementia, under legal guardianship, was administered antipsychotic medication without an active court-approved treatment plan, as required by facility policy. The expired treatment plan was not updated, and the resident continued to receive Clozapine without proper legal authorization.
A resident with a diagnosis of schizoaffective disorder was admitted after a psychiatric hospitalization without an accurate PASRR Level I screening, as the form failed to indicate the mental disorder and recent psychiatric stay, resulting in no Level II evaluation. The absence of a Social Worker overseeing the PASRR process contributed to the deficiency, as confirmed by the Administrator.
A resident with hypotension and dysphagia did not have pharmacy consultant recommendations regarding as-needed cough syrup and menthol lozenges addressed or documented in a timely manner. Recommendations made over two consecutive months were not communicated to the physician or acted upon until more than two months later, and the related reports were missing from the medical record.
A resident with a neurogenic bladder and indwelling Foley catheter was observed on multiple occasions with the catheter drainage bag lying directly on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed knowledge that catheter bags should not touch the floor, yet the deficiency was observed during the survey.
The facility did not submit direct care staffing data to CMS for FY Quarter 1 2024. The CMS PBJ Staffing Data Report showed missing data for the quarter. Interviews revealed that the Nursing Staff Scheduler was unaware of the reporting responsibility, and Consulting Staff #5 identified missing data from October 1-15 due to previous owners' inaction. The Administrator was unaware of the issue before his employment, and Consulting Staff #4 confirmed the previous owners' failure to submit the data.
The facility failed to maintain an effective infection prevention and control program, lacking a system for tracking potential infections. A resident did not receive proper Enhanced Barrier Precautions (EBP) as staff failed to wear required PPE during high-contact care. Another resident was transferred without EBP, and staff were unaware of the necessary precautions. The facility had not fully implemented EBP despite receiving guidance.
The facility failed to maintain a clean and homelike environment, with surveyors observing broken heaters, stained curtains, and damaged windows across two care units. Interviews revealed a lack of awareness and systematic maintenance, with the Maintenance Director unaware of damages and the Administrator acknowledging inadequate rounding processes. The facility's policy on maintaining a safe environment was not effectively implemented, contributing to the deficiencies.
The facility failed to provide adequate supervision and an environment free from accidents for three residents. One resident experienced multiple falls without proper risk assessments or interventions. Another resident's care plan was not updated after falls, and a third resident was at risk for elopement due to incomplete assessments and expired wanderguard management.
The facility failed to provide proper respiratory care for four residents, including missing physician orders for oxygen therapy, lack of respiratory care plans, and improper storage and maintenance of nebulizer and oxygen equipment. Observations revealed outdated and unclean equipment, and interviews with staff confirmed these deficiencies.
The facility failed to address and document pharmacy consultant recommendations for three residents, leading to unaddressed medication regimen reviews. A resident's antipsychotic medication diagnosis was not updated timely, another resident did not receive a necessary AIMS assessment, and a third resident's medication dosages and PRN usage were not reviewed as recommended. The DON acknowledged the lack of a tracking system for these recommendations.
The facility failed to ensure proper medication administration and storage, leading to deficiencies. A resident with cognitive impairment had medications left unattended without an order to self-administer. Medication carts were observed unlocked and unattended, contrary to policy. Additionally, medications were improperly stored, with loose pills left uncovered and unlabeled. The DON confirmed these practices were against facility policy.
The facility failed to provide pneumococcal vaccinations to three residents as per policy and CDC guidelines. The residents' records lacked documentation of screening, eligibility assessment, and education, with consent forms left incomplete. An IPN confirmed these deficiencies, noting the residents were not up to date with their vaccinations.
The facility failed to provide timely and appropriate Medicare coverage notices to two residents, resulting in their health care proxies not being informed about the appeal process for services ending. Incorrect forms were issued, and notifications were inadequately communicated, leading to missed appeal opportunities.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with respiratory failure and another with PTSD. The first resident did not receive a written summary of their care plan, while the second resident's PTSD was not addressed in their care plan, leading to unmet needs and potential distress. Staff interviews revealed a lack of awareness and execution of care planning policies.
A resident with severe cognitive impairment and a history of falls did not receive the prescribed interventions from their Falls Care Plan. Observations showed missing non-skid strips and incorrect placement of Dycem on the wheelchair cushion. Staff interviews confirmed these oversights, attributing them to a room change, but acknowledged that interventions should have followed the resident.
A resident dependent on staff for ADLs and personal hygiene was found with long, dirty fingernails, indicating a failure in nail care provision. Despite being cognitively intact and expressing embarrassment over their nail condition, there was no documentation of recent nail care or refusal of such care. Interviews with CNAs and nursing staff revealed inconsistencies in nail care practices, with no specific schedule or documentation, leading to the deficiency.
The facility failed to provide proper catheter care for three residents, including not assessing the need for a Foley catheter, lacking physician orders for catheter care, and improperly positioning catheter bags above the bladder. These actions led to deficiencies in catheter management and increased risk of complications.
A resident with PTSD and depression did not receive trauma-informed care at the facility. The resident's PTSD was not documented in the Nursing Admission Assessment, and no PTSD Assessment was completed. Consequently, no care plan was developed to identify and mitigate trauma triggers. Interviews revealed that the resident was not asked about their trauma or potential triggers, and staff confirmed the absence of a care plan, failing to follow facility policy and guidelines.
A resident with severe cognitive impairment and anxiety was prescribed PRN Lorazepam without a stop or re-evaluation date, contrary to the facility's policy requiring re-evaluation after 14 days. The order was left open-ended, and the facility did not provide the full pharmacist recommendation. Interviews confirmed the need for clarification and re-evaluation.
The facility failed to ensure accurate MDS assessments for three residents. A resident's falls were not documented, another's hospice status was omitted, and a third resident's Foley catheter use was not recorded. MDS Nurse #1 acknowledged these inaccuracies during interviews.
A facility failed to maintain accurate medical records for a resident, as their electronic medical record contained documents not relevant to them. An informed consent document was scanned multiple times into the record, but it was actually a consent to treat for another resident. The DON and medical records staff confirmed the error.
A resident with a DVT did not receive the prescribed anticoagulant medication due to a pharmacy delay, and the Physician was not notified. The resident's condition worsened, leading to hospitalization and emergency surgery.
A resident with deep vein thrombosis (DVT) did not receive their prescribed anticoagulant medication, Eliquis, in a timely manner due to a nurse selecting the wrong pharmacy in the electronic medical record system. The error was not identified or corrected, resulting in the resident's hospitalization for increased pain and skin color changes in the affected leg.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to CMS for the entire reporting period of Fiscal Year Quarter 2 2025, as required by federal regulations. Review of the facility's policy indicated that it is their standard to submit timely and accurate staffing information, including agency and contract staff, in the format and schedule specified by CMS. However, the PBJ Staffing Report and CASPER Report 1705D for the relevant quarter showed that no data was submitted, resulting in a one-star staffing rating, excessively low weekend staffing, multiple days with no RN hours, and several days without 24-hour licensed nurse coverage. Interviews with facility leadership revealed that there was confusion and miscommunication regarding the submission of PBJ data. The Administrator initially believed the data had been reported but could not provide evidence of submission. The Director of Operations acknowledged an issue affecting all company buildings and stated that they were in contact with CMS. The Regional Clinical Nurse explained that the person responsible for PBJ submissions had been terminated about a month prior, and the company was under the impression that the data had been submitted. Ultimately, the Administrator confirmed that corporate was responsible for the submission, but it had not occurred for the specified quarter.
Antipsychotic Medication Administered Without Active Court-Approved Treatment Plan
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medication was active and current for a resident with a legal guardian. The facility's policy requires that residents with guardians must have a valid court-approved treatment plan in place before antipsychotic medications can be administered. Record review showed that the resident, who had diagnoses including schizophrenia and dementia, was under guardianship and had previously been authorized to receive antipsychotic medication through a court-approved treatment plan. However, this treatment plan had expired, and there was no updated or current plan in the medical record. Despite the expiration of the treatment plan, the resident continued to receive Clozapine as ordered by the physician, as documented in the Medication Administration Records. Interviews with the Administrator confirmed that there was no active or updated court-approved treatment plan available, and the most recent plan had expired. The facility did not have a social worker at the time, and efforts to locate or update the necessary documentation were unsuccessful.
Failure to Accurately Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed prior to the admission of a resident with a known mental disorder. The resident was admitted following a seven-week psychiatric hospitalization and had a diagnosis of schizoaffective disorder. However, the PASRR Level I screening form did not indicate the presence of this mental disorder, as the relevant box for schizoaffective disorder was not checked. Additionally, the form did not reflect the recent inpatient psychiatric hospitalization, and the screening results were marked as negative for serious mental illness (SMI), leading to no Level II PASRR evaluation being conducted. Further review revealed that there was no additional information in the PASRR electronic portal or with the PASRR office regarding the Level I screen for this resident, and no evidence of a Level II PASRR evaluation. During an interview, the Administrator confirmed the absence of a Social Worker responsible for PASRR oversight at the time, which contributed to the failure in the screening process. The deficiency was identified through record review and staff interview.
Failure to Timely Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review (MRR) recommendations made by the pharmacy consultant were communicated to the physician and addressed in a timely manner for one resident. Specifically, recommendations made in August and September 2024 to evaluate the continued use of as-needed Geri-tussin (cough syrup) and menthol lozenge were not reviewed or responded to by the provider until November 4, 2024, which was 80 days after the initial recommendation. The pharmacy consultant's reports from August and September were also not found in the resident's medical record, indicating a lapse in documentation and follow-through with established policy requirements. The resident involved had a history of hypotension and dysphagia and had been prescribed Geri-tussin syrup and menthol lozenges on an as-needed basis, both of which were discontinued on November 4, 2024. Facility policy required that pharmacy consultant recommendations be acted upon within relevant time frames and documented in the resident's medical record. During an interview, the DON confirmed that the recommendations were not addressed in a timely manner and that the relevant reports could not be located in the resident's record.
Failure to Maintain Sanitary Foley Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the care of a resident with an indwelling Foley catheter. Observations on two separate dates revealed that the resident's catheter drainage bag was not attached to the bed and was lying directly on the floor without any protective barrier. This practice was not in accordance with both CDC guidelines and the facility's own policy, which require that catheter bags be kept off the floor and below the level of the bladder to prevent contamination. The resident involved had a history of urinary retention and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. Documentation confirmed the presence of physician orders and care plans for catheter care. Interviews with multiple staff members, including CNAs, a nurse, and the Director of Nurses, consistently indicated awareness that catheter bags should be hanging from the bed or wheelchair and not resting on the floor. Despite this, the deficiency was observed during the survey.
Failure to Submit Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 1 2024, which spans from October 1 to December 31. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, which indicated that the facility did not submit the required data for the quarter. Interviews conducted on May 8, 2024, revealed that the Nursing Staff Scheduler was unaware of who was responsible for PBJ reporting. Consulting Staff #5 noted that data from October 1-15 was missing, likely due to the previous owners not filing it, which resulted in the data submission being incomplete. The Administrator, who was not aware of the reporting status before his employment, deferred questions to Consulting Staff #4, who confirmed that the previous owners should have submitted the data but was unsure why it was not done.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a complete system of surveillance to identify trends of actual or potential infections. The Infection Preventionist (IP) admitted to not keeping a line listing of illnesses that do not require antibiotics, and there was no documentation of daily surveillance activities. This lack of documentation and tracking hindered the facility's ability to identify and address potential spreads of illnesses among residents, employees, and visitors. For Resident #36, the facility did not ensure that staff wore the required personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). A Certified Nursing Assistant (CNA) was observed providing high-contact care without wearing a gown, despite a sign indicating the need for both a gown and gloves. The CNA was unaware of the resident's precaution status, and the CNA care card did not reflect the necessary precautions. The Director of Nursing (DON) acknowledged the oversight and noted that staff education on EBP had not been completed. Resident #160 was also not provided with the necessary EBP, as staff members were observed transferring the resident without wearing gowns. There was no EBP sign or PPE available near the resident's room, and the comprehensive care plan did not include EBP. Interviews with staff revealed a lack of understanding and implementation of EBP, with the DON confirming that the facility had not yet rolled out the necessary precautions, despite receiving guidance from CMS and CDC.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as observed by surveyors. The surveyors noted multiple deficiencies across two resident care units, including broken baseboard heaters, dirty and stained window curtains, broken window blinds, and rust around bathroom fixtures. Additionally, there were instances of cracked and broken windows, scuffed walls, and damaged furniture, all of which contributed to an environment that was not well-kept or homelike. Interviews with facility staff revealed a lack of awareness and a systematic approach to addressing these issues. The Maintenance Director admitted to not having a schedule for routine maintenance rounds and was unaware of the damages until shown by the surveyor. The Administrator acknowledged that the facility's rounding process was inadequate and that the Maintenance Director was not involved in it. Furthermore, the Administrator noted that while department heads were assigned to check rooms and areas, there was no effective tracking process for these checks, resulting in unaddressed concerns. The facility's policy on maintaining a safe and homelike environment was not effectively implemented, as evidenced by the numerous environmental issues observed. The lack of a preventative maintenance policy and the absence of a structured process for identifying and addressing maintenance concerns contributed to the deficiencies. The Administrator recognized the need for improvement in the rounding process and acknowledged that the current state of the rooms was not homelike and posed safety concerns.
Failure to Prevent Falls and Elopement Risks
Penalty
Summary
The facility failed to provide adequate supervision and an environment free from accidents and hazards for three residents. For one resident, the facility did not follow its fall reduction policy by failing to investigate falls and implement fall prevention interventions. This resident experienced multiple falls, and the medical record did not show any completed fall risk assessments or interventions post-fall. The interdisciplinary care plan was not updated with new interventions after each fall, and the resident's health care proxy expressed concerns about the lack of communication and preventive measures. Another resident also experienced falls, and the facility did not develop or implement interventions to prevent recurrence. The medical record showed an incomplete fall risk assessment, and the interdisciplinary care plan was not updated with new interventions. Interviews with staff revealed that the expected procedures for updating care plans and implementing interventions were not followed, leaving the resident at risk for further falls. The facility also failed to follow its policy for managing elopement and wandering risks for a third resident. The resident had a history of elopement, but the facility did not complete an elopement risk screen upon the resident's return. The care plan lacked comprehensive interventions to prevent elopement, and the wanderguard device was not properly managed, as it was expired and not securely placed on the resident. Interviews with staff indicated that the necessary assessments and interventions were not completed, leaving the resident at risk for further elopement.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for four residents. For Resident #53, there was no physician's order for oxygen therapy despite the resident receiving it since admission. The oxygen equipment was not changed according to the facility's policy, as observed by the surveyor. Interviews with the resident, a nurse, consulting staff, and the Director of Nurses (DON) confirmed the absence of a necessary physician's order for oxygen therapy. Resident #54 did not have a respiratory care plan developed, and the nebulizer equipment was not stored or changed per policy. The nebulizer face mask was observed hanging off the nightstand and later in a drawer with personal belongings, both times unbagged, and the tubing had not been changed since admission. The resident confirmed frequent use of the nebulizer and was unsure about the tubing change frequency. Interviews with the resident and staff highlighted the lack of equipment management and care plan. For Resident #34, the nebulizer equipment was not clean, and the mask and tubing were not stored per policy. The nebulizer machine was observed with dust and debris, and the mask and tubing were left unbagged. Nurse #1 acknowledged the improper storage of the equipment. Resident #1's oxygen equipment was not changed per policy, with tubing appearing old and dirty, and the humidifier bottle was unlabeled and empty. Nurse #1 confirmed the tubing was overdue for a change, posing an infection control risk. Interviews with staff, including the DON, revealed a lack of proper orders and adherence to equipment change schedules.
Failure to Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three residents. Specifically, the facility did not act upon or document the recommendations for Residents #21, #9, and #19, which included updating diagnoses, conducting necessary assessments, and reviewing medication dosages. The Director of Nursing (DON) acknowledged the absence of a tracking method to ensure recommendations were addressed and admitted that previous MRRs were not kept as part of the residents' medical records. For Resident #21, the facility did not address the consultant pharmacist's recommendations from January to March 2024 until May 2024. These recommendations included updating the diagnosis for the antipsychotic medication Seroquel and addressing the use of psychoactive PRN Trazodone. The recommendations were not signed by the physician until May 3, 2024, indicating a delay in addressing the pharmacist's suggestions. The DON confirmed that the recommendations were not scanned into the medical record or acted upon in a timely manner. Resident #9 was prescribed Olanzapine for mood disorder, and the pharmacy consultant recommended an AIMS assessment to monitor for tardive dyskinesia. However, the facility failed to include this recommendation in the resident's medical record, and the assessment was not completed. Similarly, for Resident #19, the facility did not act on recommendations to review the dosage of Escitalopram and the use of as-needed medications like Benadryl, Cepacol, and Mucinex. The recommendations were not documented or addressed, and the physician's response was incomplete.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage practices, leading to several deficiencies. For Resident #50, medications were left at the bedside without direct supervision, despite the resident not having an order or assessment to self-administer medications. This resident, who has moderate cognitive impairment and a history of hepatic encephalopathy, was observed with medication cups containing lactulose left unattended in their room. The facility's policy requires that medications be administered under supervision, and there was no documentation supporting the resident's ability to self-administer, which was confirmed by the Director of Nurses (DON). Additionally, medication and treatment carts on Unit One were repeatedly observed unlocked and unattended, with residents roaming the halls. This occurred on multiple occasions, with carts left in hallways and common areas without staff supervision. The facility's policy mandates that medication carts be locked when not in use, a requirement that was not adhered to, as confirmed by interviews with nursing staff and the DON. Furthermore, medications were improperly stored on top of medication carts and within the carts themselves. Observations included loose pills left uncovered and unlabeled, both on top of and inside the carts. Nurses admitted to leaving medications unsecured and failing to destroy or properly document unused medications. The DON confirmed that medications should be administered immediately once prepared and that any unused medications should be destroyed and documented accordingly.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policy and CDC recommendations regarding pneumococcal vaccinations for three residents. The policy required offering and administering the vaccine to eligible individuals, providing education, obtaining consent, and documenting the process. However, for Residents #9, #13, and #34, there was no documentation of screening, assessment for eligibility, or education provided. Additionally, the consent forms for these residents were blank and incomplete, indicating a lack of compliance with the facility's vaccination procedures. Resident #9, admitted in April 2024, had no record of receiving any pneumococcal vaccinations, and the medical record lacked necessary documentation. Resident #13, eligible for the PCV20 vaccine, also had incomplete documentation and no evidence of receiving the vaccine. Resident #34, with a diagnosis of COPD, similarly had no record of receiving the pneumococcal vaccine and incomplete documentation. The Infection Preventionist Nurse confirmed these deficiencies during an interview, acknowledging that the residents were not up to date with their vaccinations as per the facility's policy.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and appropriate notifications regarding Medicare coverage and potential liability for services not covered, specifically for two residents. The facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, and failed to issue and explain the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, in a timely manner. This resulted in the residents and their health care proxies (HCPs) not being informed about the appeal process for services that were ending. For Resident #21, the facility did not provide the SNF ABN and instead issued the incorrect form, ABN, Form CMS-R131. The NOMNC was communicated via a voicemail, and there was no evidence that a physical copy was mailed or that a discussion took place with the HCP. The HCP was not informed about the appeal rights and expressed a desire to appeal the decision, as the resident was previously walking and eating a regular diet. The facility later found proof that the forms were received via certified mail, but this was after the appeal window had closed. Similarly, for Resident #49, the facility failed to provide the correct SNF ABN and issued the ABN, Form CMS-R131 instead. The NOMNC was communicated through a phone call, and there was no documentation that the HCP was aware of the appeal rights. The HCP was not notified about the resident coming off skilled services and expressed interest in appealing, but was informed that the appeal window had closed. The facility did not have signed copies of the forms or evidence that the documents were mailed, indicating that the process was not followed correctly.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. For one resident, who was admitted with respiratory failure and required supplemental oxygen, the facility did not provide a written summary of the baseline care plan. The resident, who was cognitively intact, reported not having a meeting or receiving any documentation regarding their care plan. Interviews with facility staff revealed a lack of awareness and execution of the policy to provide residents with a copy of their baseline care plan. Another resident, admitted with PTSD and depression, did not have a baseline care plan developed for their PTSD. The facility's policy on trauma-informed care was not followed, as there was no assessment or identification of triggers that could re-traumatize the resident. The resident expressed that no one had discussed their PTSD or potential triggers, which caused them anxiety. Interviews with staff indicated that the necessary assessments and care plans were not completed, and there was a lack of understanding of the facility's policy and regulatory guidelines. The deficiencies highlight a failure in the facility's processes to ensure timely and appropriate care planning for new admissions. The lack of baseline care plans and communication with residents about their care needs and preferences resulted in unmet immediate needs and potential distress for the residents involved.
Failure to Implement Falls Care Plan Interventions
Penalty
Summary
The facility failed to implement interventions on the Falls Care Plan for a resident, leading to a deficiency in meeting the resident's physical, psychosocial, and functional needs. The resident, admitted in January 2024, had diagnoses including dementia, muscle weakness, unsteadiness on feet, and a history of a right hip traumatic fracture. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of recent falls. The care plan included interventions such as placing non-skid strips next to the bed and in front of the closet, and using Dycem on the wheelchair cushion to prevent falls. Observations by the surveyor revealed that these interventions were not implemented. On multiple occasions, the surveyor noted the absence of non-skid strips and the incorrect placement of Dycem under the wheelchair cushion instead of on top. Interviews with nursing staff and the Director of Nurses confirmed the lack of adherence to the care plan, with explanations suggesting a room change might have contributed to the oversight. However, the expectation was that interventions should follow the resident with any room changes, which did not occur in this case.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living (ADLs) and personal hygiene. The resident, who was cognitively intact, expressed embarrassment over the condition of their long and dirty fingernails, which had not been trimmed or cleaned by staff. Despite being dependent on staff for grooming, the facility's documentation did not indicate when the resident last received nail care, nor did it document any refusal of such care by the resident. Interviews with Certified Nurse Assistants (CNAs) and nursing staff revealed inconsistencies in the provision of nail care. While CNAs acknowledged that nail care should be performed during shower days or as needed, there was no specific schedule or documentation of nail care being provided. The Director of Nursing (DON) confirmed that staff are expected to assess and address nail care needs during daily care and shower days, and any refusal of care should be documented. However, the lack of documentation and the resident's reports indicate that these procedures were not consistently followed, leading to the deficiency.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and management for three residents, leading to deficiencies in catheter assessment, care orders, and positioning. For one resident, the facility did not assess the necessity of a Foley catheter upon admission, nor did it attempt a voiding trial or consult with a urologist to determine the need for continued catheter use. The resident expressed a desire to have the catheter removed, but no explanation or action was taken by the facility staff. Another resident was admitted with a Foley catheter, but the facility failed to have physician orders for the catheter and its care. Observations showed that the catheter drainage bag was repeatedly positioned above the bladder, attached to the armrest of the resident's wheelchair, which is contrary to best practices for preventing urinary tract infections. Despite multiple interactions with staff, the improper positioning of the catheter bag was not corrected. A third resident also had a Foley catheter drainage bag improperly positioned above the bladder on the wheelchair armrest. This occurred multiple times, with various staff members failing to adjust the bag despite interacting with the resident. The resident indicated that staff placed the bag on the armrest, contradicting a staff member's claim that the resident did it independently. The facility's care plan did not reflect any resident preference for this positioning, indicating a lack of proper documentation and adherence to care protocols.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for Resident #109, who was diagnosed with post-traumatic stress disorder (PTSD) and depression. Upon admission in April 2024, the Nursing Admission Assessment did not indicate a diagnosis of PTSD, although the Minimum Data Set (MDS) assessment later confirmed it. The Social Services Assessment was incomplete, and there was no evidence of a PTSD Assessment being conducted. Consequently, the facility did not develop a baseline or comprehensive care plan to identify and mitigate potential trauma triggers for Resident #109. Interviews revealed that Resident #109 had not been asked about their PTSD, the nature of their trauma, or potential triggers. The resident expressed anxiety about being in closed spaces with males and indicated that no measures had been discussed to prevent re-traumatization. The Social Worker admitted to not completing a PTSD assessment and acknowledged the absence of a care plan for PTSD, which should have been in place to identify and avoid triggers. Nurse #1 confirmed the lack of a PTSD care plan in the resident's medical record, indicating a failure to adhere to facility policy and regulatory guidelines.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Lorazepam, was re-evaluated 14 days after it was prescribed, as required by standard practice. The resident, who was admitted with diagnoses including dementia, mood disorder, anxiety, and epilepsy, had a severe cognitive impairment and anxiety. The physician's order for Lorazepam did not include a stop date or re-evaluation date, which is a requirement for PRN psychotropic medications. The facility's policy mandates that all psychotropic PRN medications should be written for 14 days only and then re-evaluated. However, the Lorazepam order was left open-ended, contrary to the policy. The Consultant Pharmacist's note indicated the need to evaluate the PRN Lorazepam, but the facility did not provide the full recommendation to the surveyor. Interviews with the DON and consulting staff confirmed that the order should have been clarified and re-evaluated after 14 days, as it was not intended for seizure management.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For Resident #4, the MDS assessment did not document three falls that occurred within the facility, despite the resident's medical record indicating these incidents. MDS Nurse #1 acknowledged the oversight during an interview and confirmed that the falls should have been recorded in the MDS assessment. Resident #1's MDS assessment inaccurately reflected the resident's hospice status. Although the medical record showed that the resident was receiving hospice services with a prognosis of less than six months, the MDS assessment failed to document this information. Similarly, for Resident #160, the MDS assessment did not indicate the presence of an indwelling Foley catheter, which was noted in the resident's admission assessment and care plan. MDS Nurse #1 admitted that these details were not correctly documented and required modification for accuracy.
Inaccurate Medical Record Maintenance
Penalty
Summary
The facility failed to maintain medical records securely and accurately for one resident, leading to a deficiency. Specifically, the electronic medical record of a resident contained documents that were not relevant to them. An informed consent document for psychotropic medication was scanned into the resident's record 14 times, and upon review, it was found that the document was not an informed consent for psychotropics. Further examination revealed that the document was actually a consent to treat for another resident. During interviews, both the Director of Nurses and a medical records staff member acknowledged that these documents were incorrectly placed in the resident's medical record and should not have been there.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The Facility failed to ensure that Resident #1's Physician was notified when the prescribed anticoagulant medication, Eliquis, was unavailable for administration. Resident #1, who had been diagnosed with a deep vein thrombosis (DVT) in the left lower extremity, did not receive the first scheduled dose of Eliquis due to a delay in delivery from the pharmacy. Nurse #1 documented the unavailability of the medication but did not inform the Physician, assuming the medication would arrive with the next scheduled delivery. On the following day, Resident #1 experienced increased pain, swelling, and discoloration in the left lower extremity. Despite the worsening condition, the Physician was still not notified. The MDS Coordinator assessed Resident #1 and recommended immediate transfer to the Hospital Emergency Department (ED) due to the absence of the necessary medication and the resident's deteriorating condition. The resident was subsequently diagnosed with an acute arterial thrombosis and underwent emergency surgery. Interviews with the Nurse Practitioner, MDS Coordinator, and Director of Nurses confirmed that the Physician was not informed about the unavailability of Eliquis. The Facility's policy mandates that significant changes in a resident's condition or treatment must be communicated to the Physician, which was not adhered to in this case. This lapse in communication and failure to administer the prescribed medication led to Resident #1's hospitalization and emergency surgical intervention.
Failure to Administer Anticoagulant Medication Timely
Penalty
Summary
The facility failed to ensure that a resident diagnosed with deep vein thrombosis (DVT) received their prescribed anticoagulant medication, Eliquis, in a timely manner. The Nurse Practitioner (NP) ordered Eliquis for the resident after an ultrasound confirmed the presence of a DVT. However, the nurse responsible for entering the medication order into the electronic medical record system (Point Click Care/PCC) mistakenly selected Pharmacy B instead of Pharmacy A, which the facility uses. This error resulted in the medication order being marked as 'profile only,' meaning it was not filled by the pharmacy. The nurse did not realize that the order had been sent to the wrong pharmacy and did not follow up to ensure the medication was delivered. As a result, the resident did not receive the first scheduled dose of Eliquis. The resident experienced increased pain and skin color changes in the affected leg, leading to their transfer to the hospital for evaluation. The Director of Nursing (DON) and the Chief Nursing Officer (CNO) later discovered the error during a review of the resident's medical record and communication with the pharmacy. Interviews with the nursing staff revealed that there was confusion about the pharmacy selection process in the PCC system. The nurse who entered the order was unaware that there were two pharmacies listed and did not know that selecting the wrong pharmacy would prevent the order from being filled. The facility's policies require timely notification and follow-up with the pharmacy for medication orders, but these steps were not adequately followed in this case, leading to the resident's hospitalization.
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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