Center For Extended Care At Amherst
Inspection history, citations, penalties and survey trends for this long-term care facility in Amherst, Massachusetts.
- Location
- 150 University Drive, Amherst, Massachusetts 01002
- CMS Provider Number
- 225420
- Inspections on file
- 25
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Center For Extended Care At Amherst during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and right-sided weakness, who required two-person assistance for bed mobility, was repositioned in bed by a single CNA who did not review the care plan or CNA Care Card. The CNA attempted to change the bed sheets alone, causing the resident to fall from the bed and sustain bilateral femur fractures, leading to the resident's death. The CNA had been informed of the resident's care needs but failed to seek assistance as required.
A resident with severe cognitive impairment and right-sided weakness, who required two-person assistance for bed mobility, was left unattended by a CNA who attempted to change bed sheets alone using an ill-fitting sheet. This resulted in the resident falling from bed, sustaining bilateral femur fractures, and subsequently dying from traumatic hemorrhagic shock. The CNA did not review the care plan or seek available assistance, despite prior training and staff reminders.
A resident with multiple health conditions and a high risk for pressure ulcers experienced deterioration of a deep tissue injury after staff failed to consistently apply physician-ordered prophylactic booties while in bed. The omission of this intervention from CNA care documentation led to repeated lapses in care, resulting in the wound becoming open, painful, and exhibiting drainage.
The facility did not ensure timely delivery of meals and snacks according to residents’ needs and preferences, resulting in frequent delays across all units. A resident with diabetes reported inconsistent meal times affecting insulin administration, while another resident and a family member described significant meal delays and lack of response to alternate food requests, especially on weekends. Review of delivery logs and direct observation confirmed that meals were often delivered 20 minutes or more past scheduled times, and facility leadership acknowledged awareness of the issue.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dirty storage shelves, bins, and utility fans, as well as a milk cooler with a rancid odor and the presence of fruit flies/gnats. The Food Service Director and Director of Maintenance confirmed that cleaning schedules did not include certain areas and that sanitation concerns were present, including ongoing pest issues.
A resident with multiple diagnoses, including Vitamin D deficiency and cirrhosis, received high-dose Vitamin D (Ergocalciferol 50,000 IU weekly) for an extended period without physician orders to monitor serum Vitamin D levels. Despite documentation indicating the need for lab monitoring and dosage adjustment, no laboratory tests were ordered or performed, as confirmed by interviews with the DON, PNP, Pharmacy Consultant, and Medical Director.
A CNA was hired without the required NAR and CORI background checks being completed, in violation of facility policy. Review of the personnel file and staff interviews confirmed that these checks were not performed prior to employment, and there was no documentation to support their completion.
A resident with severe cognitive impairment was subjected to disrespectful and undignified treatment by a CNA, who used profanity and handled the resident roughly during care. Witnesses reported the CNA's inappropriate behavior, leading to the CNA's suspension and eventual termination following an investigation.
A resident reported to the Nurse Supervisor that a CNA told them they could not get out of bed to use the bathroom until morning. The Nurse Supervisor documented the allegation but did not report it to Facility Administration immediately. The DON discovered the note over four hours later, and the CNA continued to work for at least two more hours, potentially placing other residents at risk.
The facility failed to perform annual Legionella water testing, did not clean and disinfect a vital signs machine between resident uses, and did not follow proper hand hygiene and glove-changing procedures during wound care for a resident with a Stage 4 pressure ulcer.
The facility failed to maintain a clean and sanitary kitchen by not addressing a dish machine rinse temperature issue and using household bleach instead of a commercial grade chlorine-based sanitizer, leading to improper sanitization of dishware.
The facility failed to ensure a dignified existence for residents in one dining room on the Dharma Unit (DSCU). Staff were observed speaking disrespectfully about residents, referring to them as 'feeders,' and standing while assisting with meals despite available chairs. CNAs were also seen having personal conversations in a language not understood by all residents. Staff acknowledged these behaviors were inappropriate and not in line with facility policies.
The facility failed to notify the Physician/NPP of significant changes in the condition of two residents. One resident experienced multiple seizures without notification to the Physician, and another resident had a significant unplanned weight loss that was not reported. Interviews confirmed the lapses in communication and the absence of a clear notification policy.
The facility failed to ensure a homelike environment in one dining area on the Dharma Unit. Observations showed residents seated at tables without tablecloths, and meals were served directly on delivery trays. The Unit Manager acknowledged that tablecloths and removing meal items from trays would enhance the dining experience, noting that other dining areas did use tablecloths.
The facility failed to accurately code MDS Assessments for two residents. One resident receiving hospice services was not coded as such, and another resident receiving intravenous antibiotics was not coded for antibiotic use. These errors were confirmed by the Director of Nurses and the MDS Nurse.
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter by not obtaining necessary Physician's orders for catheter care, irrigation, replacement, and the application of an anchoring device. This deficiency was confirmed by both a nurse and the Director of Nurses.
The facility failed to accurately implement a gradual dose reduction (GDR) for a psychotropic medication as recommended by the Psychiatric Certified Nurse Practitioner (CNP) for a resident with anxiety disorder, Alzheimer's Dementia, and a history of psychosis. The morning dose of Zyprexa was increased back to 5 mg without further recommendations, cancelling the GDR process.
The facility failed to re-evaluate a PIP for improving lunch meal tray arrival times for the Dharma Unit. Lunch meals were often late, sometimes by 30 minutes or more, and the PIP lacked specific parameters and measurable goals. The issue persisted despite adequate staffing levels, and feedback was not obtained from the affected unit.
The facility failed to ensure that the Infection Preventionist (IP) and Medical Doctor (MD) attended the required quarterly QAPI committee meetings. The IP missed two out of four meetings, and the MD missed one. The Director of Nurses (DON) confirmed these absences and acknowledged that both were required members.
The facility failed to complete an accurate comprehensive assessment for a resident by not conducting the required Brief Interview for Mental Status (BIMS) and instead relying on staff assessments, despite the resident's ability to communicate and understand questions.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with a history of cerebral infarction resulting in right-sided weakness, severe cognitive impairment, and dependence on staff for bed mobility was not provided care according to their established care plan. The care plan, CNA Care Card, and Minimum Data Set (MDS) all specified that the resident required the assistance of two staff members for bed mobility, including turning and repositioning in bed. Despite these documented requirements, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets and reposition the resident alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and left the resident holding onto the bedrail while she moved to the other side of the bed. The fitted sheet being used was too small, causing the mattress to curl and resulting in the resident rolling out of bed and landing on their knees on the floor. The CNA then attempted to support the resident's upper body and called for help. The resident was subsequently assessed and found to have sustained bilateral distal femur fractures. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card prior to providing care, despite having received training and education on the importance of doing so. The CNA stated she was unfamiliar with the procedure for reviewing these documents and relied on verbal information from other staff. Other staff members confirmed that the CNA had been informed of the resident's need for two-person assistance but did not seek help when it was available. The failure to follow the care plan interventions directly led to the resident's fall, injuries, and subsequent death.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall and Fatal Injury
Penalty
Summary
A deficiency occurred when a resident with right-sided weakness from a stroke, severe cognitive impairment, and a care plan requiring assistance from two staff members for bed mobility was not provided the necessary level of staff assistance. The resident was dependent on staff for turning and repositioning in bed, had upper and lower extremity limitations, and was at risk of injury. Despite these documented needs, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and proceeded to change the fitted sheet, which was too small for the mattress. This caused the mattress to curl up, resulting in the resident rolling out of bed and landing on their knees. The CNA attempted to support the resident after the fall, but no other staff were present at the time. The resident sustained bilateral distal femur fractures and was subsequently transferred to the hospital, where they died the following day due to traumatic hemorrhagic shock. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card to confirm the required level of assistance, instead relying on verbal information from other staff. The CNA had received training on safe patient handling and the use of care plans but was unfamiliar with the facility's procedures for reviewing these documents. Other staff members had informed the CNA of the resident's need for two-person assistance and had offered to help, but the CNA did not seek assistance when providing care.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the deterioration of a pressure ulcer for a resident with multiple comorbidities, including diabetes, Parkinson's disease, and dementia. The resident was admitted with a history of pressure ulcer risk and was found to have a deep tissue injury (DTI) on the left ankle. Physician orders were in place for the use of prophylactic booties while in bed to prevent further skin breakdown, as well as topical treatments. However, repeated observations by surveyors revealed that the resident was not wearing the prescribed booties while in bed, and the booties were often found on a chair at the foot of the bed instead of on the resident. The resident reported pain and was aware that the booties should be worn, but stated that staff did not always remember to apply them. There was also visible evidence of wound drainage on the bed linens, and the resident's wound was observed to have deteriorated from a DTI to an open wound with swelling, redness, and severe pain. Interviews with nursing staff and review of documentation revealed that the physician's order for booties was not included in the CNA care Kardex or the Point of Care (POC) documentation, which are used to communicate care needs to direct care staff. Both the nurse and the wound care nurse acknowledged that the omission of this intervention from the Kardex and POC meant that CNAs were not consistently aware of the need to apply the booties. The wound care nurse also indicated that the wound had worsened and that she should have been notified sooner about changes in the wound's condition. There was no documentation of the resident refusing care, and staff confirmed that the booties should have been applied as ordered. Medical record review showed that the resident's wound was initially intact but later became scabbed and then open, with no evidence that changes in the wound's condition were reported to the physician or wound care nurse in a timely manner. The resident required substantial assistance for bed mobility and dressing, further emphasizing the need for staff to ensure interventions were implemented. The lack of communication and documentation regarding the booties, as well as the failure to consistently apply them as ordered, directly contributed to the deterioration of the resident's pressure ulcer.
Failure to Provide Timely Meal Delivery and Coordinate with Medication Administration
Penalty
Summary
The facility failed to ensure that meals and snacks were served in accordance with residents’ needs, preferences, and requests, particularly regarding timely delivery and coordination with medication administration. Observations, interviews, and record reviews revealed that meal trays were consistently delivered late across all three units observed. Residents reported significant delays, with one diabetic resident noting that the timing of meal delivery was inconsistent and impacted the administration of insulin. Another resident and several others agreed that meals were not delivered on time, and a family member reported that late meal delivery affected the timing and effectiveness of medications, especially those intended to assist with sleep. Requests for alternate food items also experienced delays, sometimes taking up to 30 minutes, and on weekends, kitchen staff were often unavailable to respond to requests, leading family members to bring food from home. Review of the facility’s Food Truck Delivery Daily Tracking Logs showed that on 25 out of 29 days, meals were delivered 20 minutes or more after the scheduled time. Surveyors directly observed multiple instances of late meal delivery, with food trucks arriving significantly past their scheduled times. The Food Service Director acknowledged being aware of occasional late meals but was not aware of the consistency or extent of the issue, as she did not routinely review delivery logs unless a concern was raised. The Administrator also confirmed awareness of the ongoing problem with meal delivery times.
Failure to Maintain Sanitary Kitchen Conditions and Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards and its own sanitation policy. During multiple observations, surveyors found that storage areas for resident food and fluids were not kept clean and were affected by foul odors. Specifically, a milk cooler emitted a strong rancid odor and contained puddles of water and milk, and there was a presence of fruit flies and gnats in the kitchen. Shelves and bins designated for clean pots, pans, and utensils were found to be dirty, with visible dirt, grease, and food particles present. Additionally, utility fans in both storage and preparation areas were thickly covered with dust and dirt and were not routinely cleaned. Interviews with the Food Service Director (FSD) and the Director of Maintenance revealed that cleaning tasks for shelving and bins were not included in the kitchen's cleaning schedule, and utility fans were only cleaned when notified by dietary staff. The FSD acknowledged that the observed sanitation issues posed an infection control concern, and the Director of Maintenance confirmed that the fruit fly/gnat issue had persisted for about a month. The utility fans, intended to help with the insect problem, were not routinely cleaned and should not have been in the kitchen if dirty.
Failure to Monitor Serum Vitamin D Levels During High-Dose Therapy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not obtaining physician orders to monitor serum laboratory results for a resident receiving high-dose Vitamin D therapy. The resident, who had diagnoses including metabolic encephalopathy, Vitamin D deficiency, cirrhosis of the liver, and dementia, was prescribed Ergocalciferol (Vitamin D) 50,000 IU weekly for an extended period. Despite physician progress notes indicating the need to recheck Vitamin D levels and adjust the dosage accordingly, there were no orders or evidence that serum Vitamin D levels were monitored or obtained during the resident's stay. Interviews with facility staff, including the DON, PNP, Pharmacy Consultant, and Medical Director, confirmed that no serum Vitamin D laboratory levels had been ordered or drawn for the resident. The Pharmacy Consultant was unaware of the ongoing high-dose therapy, and the Medical Director acknowledged that monitoring should have occurred. The lack of monitoring persisted even though the resident was at risk for Vitamin D toxicity due to prolonged high-dose administration.
Failure to Complete Required Background Checks Prior to Employment
Penalty
Summary
The facility failed to follow its own abuse prevention policies regarding background checks for new employees. Specifically, for one of three sampled employee personnel files, a Certified Nurse Aide (CNA) was hired without the required Massachusetts Nurse Aide Registry (NAR) and Criminal Offender Record Information (CORI) checks being conducted prior to employment. The facility's policy mandates that such checks be completed to ensure that no individual with a history of abuse, neglect, exploitation, or related disciplinary actions is employed. Review of the CNA's personnel file confirmed that neither the NAR nor CORI checks were performed before or upon hire. Interviews with the Human Resource Director and the Director of Nurses revealed that there was no documentation to support that these checks had been completed for the CNA, and an audit of personnel records had not been conducted. The Human Resource Director was unable to provide information about the hiring process prior to her employment, and both she and the DON acknowledged that the required checks should have been completed.
Resident Dignity Violation by CNA
Penalty
Summary
The Facility failed to ensure that a resident, who was severely cognitively impaired and dependent on staff for care, was treated with respect and dignity. On the morning of October 13, 2024, two staff members witnessed a Certified Nurse Aide (CNA) directing profanity at the resident and treating them in a demeaning manner during care. The resident, diagnosed with Alzheimer's disease and cognitive communication deficit, was totally dependent on staff for activities of daily living and mobility, and had a history of rejecting care. During the incident, the resident was calling out, and the CNA was heard using foul language and expressing frustration towards the resident. The Facility's investigation revealed that the CNA used inappropriate language and handled the resident roughly. Witnesses reported that the CNA accused the resident of being difficult and expressed an inability to deal with the resident's behavior. The incident was reported to the Nurse Supervisor, and the CNA was suspended pending investigation. The Director of Nurses confirmed that the CNA was terminated based on witness statements and the investigation findings.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The Facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of an allegation of abuse. On 03/14/24, at approximately 5:00 A.M., a resident reported to the Nurse Supervisor that a Certified Nurse Aide (CNA) told them they were not allowed to get out of bed to use the bathroom until the morning. Despite being made aware of the allegation, the Nurse Supervisor did not report it to Facility Administration immediately. The Director of Nurses (DON) discovered the progress note about the allegation at 9:30 A.M., over four hours later, and found that the CNA continued to work for at least two more hours, potentially placing other residents at risk for abuse or neglect. The resident involved was admitted to the Facility in March 2024 and had diagnoses including a left artificial knee and difficulty walking. The resident was cognitively intact and usually continent of urine, requiring partial/moderate assistance from staff for mobility and activities of daily living. The resident's Nurse Progress Note indicated they complained of a horrible night due to being told they could not use the bathroom until morning. The DON noted that the resident had urine-soaked clothing and bedding that morning, which was unusual for them. The Nurse Supervisor admitted to documenting the allegation but failing to report it to Facility Administration as required by the Facility's Abuse Policy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by three specific deficiencies. Firstly, the facility did not perform annual water testing for Legionella as required by their water management plan. The Maintenance Director admitted that no water testing had been conducted for the past two years, despite the plan's stipulation for annual testing using an in-house water sampling kit sent to a lab. This lapse was confirmed during interviews and a review of the facility's water management plan, which was last revised in January 2023. Secondly, the facility did not adhere to its policy on cleaning and disinfecting reusable resident-care items and equipment. Observations revealed that a nurse used a portable vital signs machine on multiple residents without cleaning or disinfecting it between uses. Despite the facility's policy requiring such equipment to be cleaned and disinfected between residents, the nurse admitted to not following this protocol during the surveyor's observations. Lastly, the facility failed to follow proper hand hygiene and glove-changing procedures during wound care for a resident with severe cognitive impairment and a Stage 4 pressure ulcer. The nurse did not change gloves or perform hand hygiene after cleaning the wound and before applying new dressings. Additionally, the nurse contaminated clean items by handling them with the same gloves used during the wound care procedure. This breach in infection control was acknowledged by the Unit Manager during an interview with the surveyor.
Failure to Maintain Proper Kitchen Sanitization
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. Specifically, the facility did not address a rinse temperature issue with the dish machine, which consistently failed to meet the required minimum temperature of 180 degrees for sanitization. Despite the dish machine's rinse temperature reading only 170 degrees, the Food Service Director (FSD) and dietary staff continued to use the machine, re-washing dishes repeatedly in an attempt to reach the required temperature. Additionally, the facility had been using household bleach instead of a commercial grade chlorine-based sanitizer in the dish machine, which was not in accordance with professional standards. During observations, the surveyor noted that the dish machine's rinse temperature was as low as 162 degrees, and dietary staff were still putting away dishes for future use without meeting the required sanitization temperature. The FSD admitted that the dish machine had been an issue for the last two months and that they were waiting for a booster device to be delivered. The FSD also confirmed that household bleach was being used to sanitize the dishware, following a recommendation from a dish machine representative, although this was not verified by the vendor. Interviews with the Administrator and Consulting Staff revealed that the Administrator was unaware of the use of household bleach and that the proper commercial grade chlorine-based sanitizer had been installed only after the surveyor's observations. The vendor confirmed that they had never advised the use of household bleach and emphasized that it was not an appropriate substitute for the commercial grade sanitizer. The facility's failure to maintain proper sanitization practices and use the correct sanitizing agents led to the deficiency noted in the report.
Failure to Ensure Dignified Existence for Residents During Meals
Penalty
Summary
The facility failed to ensure a dignified existence for residents in one of the three dining rooms observed on the Dharma Unit (Dementia Special Care Unit - DSCU). Staff members were observed speaking disrespectfully about residents, referring to them as 'feeders' and discussing their care needs loudly enough for all in the dining room to hear. Additionally, staff members were seen standing while assisting residents with their meals, despite the availability of empty chairs, which goes against the facility's policy of feeding residents with attention to safety, comfort, and dignity. Certified Nurses Aides (CNAs) were also observed having personal conversations in a language not understood by all residents at the table, further compromising the residents' dignity and comfort during meal times. During interviews, various staff members, including the Unit Manager and the Dharma Unit Activities Director, acknowledged that the observed behaviors were inappropriate and not in line with the facility's policies. The Unit Manager confirmed that staff should be seated at the residents' level while assisting with meals and should use residents' names rather than referring to them by their care needs. The Dharma Unit Activities Director also stated that residents should not be referred to as 'feeds' and that more respectful language should be used. These observations and interviews highlight a failure to adhere to the facility's policies on treating residents with dignity and respect during meal times.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the Physician/Non-Physician Practitioner (NPP) of significant changes in the condition of two residents. Resident #54, who was admitted with diagnoses including idiopathic epilepsy and conversion disorder, experienced multiple seizure episodes over several months. Despite these recurrent seizures, the facility staff did not notify the Physician/NPP on any of the documented occasions. Interviews with the nursing staff and the NPP confirmed that the Physician/NPP was not informed of Resident #54's seizure activities, which was against the expected protocol for such medical events. The Director of Nurses (DON) also admitted that there was no policy on Physician/NPP notification for seizures, and she believed the seizures were not genuine, hence no notification was made. Resident #74, admitted with diagnoses including a urinary tract infection and a fracture of the upper end of the left humerus, experienced a significant unplanned weight loss within one month. The resident's weight dropped from 111.5 lbs to 104.5 lbs, a 6.28% loss. Despite the facility's care plan indicating that significant weight loss should be reported to the Physician, there was no documentation that the Physician/NPP was notified of this change. Interviews with the DON and the Doctor of Nursing Practice (DNP) confirmed that the Physician/NPP was not informed about the weight loss, which was a clear deviation from the facility's care plan and expected protocol. These deficiencies highlight the facility's failure to adhere to protocols for notifying medical practitioners about significant changes in residents' conditions. This lack of communication could potentially impact the residents' health and treatment plans. The facility staff, including the DON, acknowledged the lapses in communication and the absence of a clear policy for such notifications, which contributed to the oversight in both cases.
Failure to Maintain Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment in one of the three dining areas on the Dharma Unit, specifically the [NAME] dining area. Observations on multiple dates revealed that residents were seated at tables without tablecloths, and meals were served directly on delivery trays without being removed and set up in front of the residents. During an interview, the Unit Manager acknowledged that the dining experience would be more homelike with tablecloths and that staff previously removed meal items from delivery trays but had not done so for some time. The other two dining areas on the Dharma Unit did use tablecloths, highlighting an inconsistency in the facility's approach to creating a homelike environment for residents.
Inaccurate MDS Coding for Hospice and Antibiotic Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two residents. Resident #101, who was admitted with chronic respiratory failure, heart failure, and multiple sclerosis, was receiving hospice services starting on 3/4/24. However, the Significant Change MDS assessment did not reflect that the resident was receiving hospice services, despite the care plan and physician's orders indicating otherwise. The Director of Nurses confirmed that the MDS was inaccurately coded during an interview on 4/8/24. Resident #122, admitted with diagnoses including retention of urine, bacteremia, sepsis, and a urinary tract infection, was prescribed and administered intravenous Ampicillin Sodium from 3/2/24 to 3/10/24. However, the MDS assessment did not indicate that the resident was receiving antibiotic medication during the look-back period. The MDS Nurse acknowledged the coding error during an interview on 4/10/24 after reviewing the resident's clinical record.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services to maintain bladder function for a resident with an indwelling urinary catheter. Specifically, the staff did not obtain the necessary Physician's orders for the care and services of the catheter, which included orders for catheter care every shift, instructions for irrigation/flushing, replacement of the catheter, replacement of the bedside drainage bag, and the application of an anchoring device. This deficiency was identified for one resident out of a sample of 25 residents, who was admitted with diagnoses of urine retention, chronic kidney disease stage 2, and a urinary tract infection. During an observation and interview, a nurse confirmed the absence of the required Physician's orders and acknowledged that there should have been more orders in place for the care of the indwelling urinary catheter. The Director of Nurses also confirmed that the orders should have been put in place but were not. The facility did not have a specific policy for the care of indwelling urinary catheters, relying instead on a Physician's order set that was not implemented for this resident.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to accurately implement a gradual dose reduction (GDR) for a psychotropic medication as recommended by the Psychiatric Certified Nurse Practitioner (CNP) for a resident. The resident, who had diagnoses including anxiety disorder, Alzheimer's Dementia, and a history of psychosis, was recommended to have their morning dose of Zyprexa reduced from 5 mg to 2.5 mg. However, the morning dose was later increased back to 5 mg without any further recommendations, thereby cancelling the GDR process. This discrepancy was not documented or explained by any of the resident's medical providers. The Psychiatric CNP confirmed that her recommendation was for the resident to have 2.5 mg of Zyprexa in the morning and to reduce the evening dose to 2.5 mg as well, which was not followed. The Unit Manager also confirmed that the morning dose should have remained at 2.5 mg and acknowledged that the doses appeared to have been swapped, resulting in the resident not receiving the full GDR as recommended. This failure to follow the recommended GDR process was identified through interviews and record reviews conducted by the surveyors.
Failure to Re-evaluate Performance Improvement Plan for Lunch Meal Delivery
Penalty
Summary
The facility failed to re-evaluate a performance improvement plan (PIP) when the identified interventions were no longer making progress toward the goal of improving lunch meal tray arrival times for the Dharma Unit. Specifically, the facility did not maintain an effective system for implementing changes, monitoring performance, and obtaining feedback from residents and family representatives regarding consistently late lunch meals. Interviews with family members revealed that lunch meals were often late, sometimes by 30 minutes or more. The Food Service Director (FSD) acknowledged the issue and attributed it to short staffing in the kitchen, although records showed that staffing levels were generally adequate except for one day. The PIP lacked specific parameters for measuring lateness and did not set measurable goals to determine if interventions were effective. Review of the Food Truck Delivery Daily Tracking Log indicated that lunch meals were late on 10 out of 15 days for the Dharma Unit, with some delays exceeding 20 minutes. The Dietary Department QAPI sheets from February and March 2024 documented late meal deliveries but did not specify which units were affected, the reasons for the delays, or any new interventions to address the issue. The Administrator admitted that interventions should have been adjusted when the problem persisted and that there was no current process to obtain feedback from residents and family members of the Dharma Unit. Feedback was only collected from the facility's other two units, not from the affected Dharma Unit.
Failure to Include Required Members in QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that the required members were included in the Quality Assurance and Performance Improvement (QAPI) committee meetings. Specifically, the Infection Preventionist (IP) was not designated as a required member of the QAPI Committee in the facility's policy and did not attend two out of the four quarterly meetings. Additionally, the Medical Doctor (MD) did not attend one out of the four quarterly meetings. The quarterly QAPI Committee sign-in sheets provided by the facility confirmed these absences. During an interview, the Director of Nurses (DON) acknowledged that both the IP and the MD were required members of the QAPI Committee and should have attended all four quarterly meetings as required.
Failure to Conduct Proper Cognitive Assessment
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident, identified as Resident #77, according to the required Resident Assessment Instrument (RAI) process. Specifically, the facility staff did not assess the resident's cognitive status through the resident interview process and instead proceeded to the staff interview process on three consecutive Minimum Data Set (MDS) Assessments. Despite the resident having adequate hearing, clear speech, and the ability to make themselves understood, the Brief Interview for Mental Status (BIMS) was not conducted, and the responses were left blank. Instead, the staff assessment for mental status was completed, which was not in compliance with the required procedure. Resident #77 was admitted to the facility with diagnoses including psychosis and post-traumatic stress disorder (PTSD). The surveyor observed that the resident could communicate clearly and understood questions asked in English. During interviews, both the MDS Nurse and the Director of Nurses (DON) acknowledged that the staff assessments should have included an attempt to conduct the resident interview for the BIMS assessments, but this was not done as required. This failure to follow the proper assessment protocol led to the deficiency noted in the report.
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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