Champion Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brockton, Massachusetts.
- Location
- 2 Beaumont Avenue, Brockton, Massachusetts 02302
- CMS Provider Number
- 225221
- Inspections on file
- 15
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Champion Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific needs such as smoking supervision, epilepsy management, and monitoring for suicidal ideation. One resident required supervision while smoking, another had frequent seizures without a care plan for triggers, and a third had a history of suicidal ideation without a mental health care plan. Staff were unaware of these needs, and the DON acknowledged the oversights.
The facility failed to provide trauma-informed care to three residents, each with PTSD or a history of trauma. A resident admitted with PTSD did not receive a trauma assessment, and staff were unaware of their trauma history. Another resident, newly diagnosed with PTSD, lacked a completed Trauma Questionnaire and specific care plan triggers. A third resident with a history of abuse did not have a trauma assessment or care plan addressing their PTSD. Staff interviews revealed a lack of awareness and completion of necessary assessments.
The facility failed to ensure proper hand hygiene during meal service, as observed by surveyors on two units. Nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents, despite the facility's policy requiring it to prevent infection spread. The Food Service Manager confirmed the oversight during an interview.
A resident with epilepsy experienced frequent seizures, but the LTC facility failed to schedule recommended Neurology and Epilepsy Center appointments. Despite initial refusal, the resident later agreed to an inpatient evaluation, yet the facility did not follow through. Interviews revealed staff were unaware of the appointment status, and the facility did not contact the Epilepsy Center to confirm insurance acceptance.
A resident with dementia and on hospice care developed a stage 3 pressure ulcer on the sacrum, and the facility failed to implement the ordered treatments. Communication lapses and incorrect wound care practices, including the use of wrong supplies and poor hand hygiene, contributed to the deficiency. The DON acknowledged that treatment orders were not updated timely, leading to missed treatments.
A resident with muscular dystrophy and cognitive intactness was not provided with adequate supervision and safety measures while smoking, as required by their care plan. The facility failed to conduct quarterly smoking evaluations and did not ensure the use of an adaptive ashtray, leading to unsafe smoking practices. Staff supervision was inadequate, with the resident being observed smoking unsafely and other residents assisting them, contrary to facility policy.
A resident with moderate cognitive impairment and epilepsy returned from a hospital stay with a Foley catheter due to urinary retention. The facility failed to assess the catheter for removal or schedule a recommended urology follow-up and voiding trial. The resident experienced catheter issues, and staff were unaware of the missed appointment, indicating a lapse in care coordination.
A resident with anoxic brain damage, dysphagia, and dementia experienced a 9.68% weight loss over six months due to the facility's failure to monitor their nutritional status. Despite a care plan goal to maintain a specific weight, weekly weights were not consistently obtained as ordered. The RD had not completed a quarterly assessment since March, and the resident was not on the list for weekly weights. The physician's notes did not acknowledge the weight loss, contributing to the oversight.
A resident was administered Azithromycin for an excessive duration of one year without adequate indication. Despite being discharged from the hospital with a 5-day antibiotic course for pneumonia, the resident continued to receive Azithromycin three times a week for COPD without documented justification. Facility staff could not provide documentation from the pulmonologist or PCP supporting the prolonged use.
A resident with severe cognitive impairment and dysphagia was observed consuming crackers, contrary to their physician-ordered pureed diet. Staff interviews revealed no documentation or physician's order allowing this deviation, highlighting a failure to adhere to the therapeutic diet, posing a risk for choking and aspiration.
A nurse failed to follow infection control protocols during wound care for a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not perform hand hygiene between glove changes and applied ointments directly from tubes onto the wound, contrary to facility policy. Interviews confirmed these lapses in infection prevention practices.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. For one resident, the facility did not create a care plan for smoking needs, despite a smoking assessment indicating the resident required supervision while smoking. The resident was observed smoking without any special instructions noted in their care plan, and the unit manager and DON acknowledged the oversight. Another resident with epilepsy did not have a care plan addressing their condition, even though they had been hospitalized multiple times due to seizures. The resident's medical record included physician orders for seizure monitoring and medication, but no care plan was developed to manage triggers and interventions. The nurse and DON confirmed the absence of a care plan, which was supposed to include known triggers like door alarms. A third resident with a history of suicidal ideation and recent psychiatric hospitalization did not have a care plan addressing their mental health needs. The CNA and unit manager were unaware of the resident's suicidal history, and the social worker admitted to not reviewing the hospital discharge summary. The DON confirmed that a care plan should have been developed to monitor for signs of worsening depression and suicidal ideation.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to three residents, as identified in a survey. Resident #36, admitted with diagnoses including dementia and PTSD, did not receive a trauma-informed care assessment upon admission. The medical record lacked information on PTSD symptoms and triggers, and staff, including a CNA and a social worker, were unaware of the resident's trauma history. The Director of Nurses acknowledged that a trauma assessment should have been completed but was not. Resident #51, who was admitted with muscular dystrophy, depression, and anxiety, received a new PTSD diagnosis after a traumatic event in July 2024. Despite this, the facility did not complete a Trauma Questionnaire, and the care plan lacked specific triggers to prevent re-traumatization. Interviews with staff revealed a lack of awareness and completion of necessary assessments, with the DON admitting that the care plan was generic and not tailored to the resident's needs. Resident #89, with a history of suicidal ideation and major depressive disorder, also did not receive a trauma assessment. The care plan did not address the resident's history of trauma, despite documentation indicating a history of sexual and physical abuse. The social worker admitted to missing information in the resident's PASARR and hospital discharge summary, resulting in a lack of a comprehensive care plan to address the resident's PTSD and associated triggers.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the area of hand hygiene during meal service. Observations by the surveyor on two separate occasions revealed that nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents. On the first occasion, some hand hygiene was observed, but it was not consistent. On the second occasion, no hand hygiene was observed at all. This lack of adherence to hand hygiene protocols occurred during meal service on two of the three units observed. The facility's policy on hand washing and hygiene, revised in August 2019, clearly states that hand hygiene is the primary means to prevent the spread of infections. It requires personnel to perform hand hygiene before and after direct contact with residents, contact with objects in the immediate vicinity of the resident, and before and after assisting a resident with meals. Despite this policy, the CNAs and nurses failed to consistently follow these procedures, as confirmed by the Food Service Manager during an interview. The FSM acknowledged the lack of hand hygiene during meal service, which is a critical step in preventing the spread of infections among high-risk residents.
Failure to Schedule Specialist Appointments for Resident with Epilepsy
Penalty
Summary
The facility failed to ensure that a resident with epilepsy had their recommended specialist appointments scheduled. The resident, who had moderate cognitive impairment, was experiencing frequent seizures and had been hospitalized recently. Despite recommendations for follow-up appointments with a Neurology office and an Epilepsy Center, the facility did not schedule these appointments. The resident initially refused an inpatient evaluation at the Epilepsy Center but later agreed, yet the facility did not follow through with scheduling. The facility's records, including the Appointment Communication Form and nursing progress notes, showed a lack of documentation and follow-up regarding the scheduling of these critical appointments. The resident continued to experience frequent seizures, and there was no evidence that the facility staff had reached out to the Epilepsy Center or Neurology office to arrange the necessary evaluations. The facility's Appointment book and nursing notes failed to indicate any progress in scheduling these appointments, despite the resident's ongoing health issues. Interviews with facility staff revealed a lack of awareness and follow-up on the resident's care plan. Nurse #4 and the Director of Nurses admitted to not knowing the status of the appointments and acknowledged that the process had been mishandled. The facility did not know that the Epilepsy Center would not accept the resident's insurance because they had not contacted the office. The Director of Nurses confirmed that the resident's condition had worsened, with more frequent seizures, and that the necessary appointments had not been made in a timely manner.
Deficiency in Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a pressure ulcer, leading to a deficiency in wound management. The resident, who was admitted with dementia and on hospice care, developed a deep tissue injury on the sacrum, which progressed to a stage 3 pressure ulcer. Despite specific treatment recommendations from both hospice and a wound consultant physician, the facility did not implement the treatments as ordered. The Treatment Administration Record (TAR) showed inconsistencies in treatment application, including missed dressing changes and incorrect implementation of wound care protocols. The deficiency was further compounded by communication lapses between the facility staff and the primary physician, as well as between the facility and hospice services. The primary physician could not recall approving changes to the treatment plan, and the hospice staff did not perform dressing changes on specified dates. Additionally, the Director of Nurses (DON) acknowledged that the treatment orders were not updated in a timely manner, resulting in a missed treatment. The wound consultant physician emphasized that the dressing should not have been left unchanged for an extended period, especially on a necrotic wound. During an observation, a nurse failed to follow proper wound care procedures, using incorrect supplies and not adhering to hand hygiene protocols. The nurse used the wrong strength of Dakins solution, incorrect calcium alginate, and ointments belonging to another resident. Furthermore, the nurse applied ointments directly from the tubes onto the wound, contrary to infection control practices. The DON and Infection Preventionist confirmed that the nurse did not follow the treatment order and failed to perform hand hygiene with each glove change, as required.
Failure to Ensure Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #51, who was cognitively intact and had a history of muscular dystrophy, ambulatory dysfunction, and generalized weakness. The resident was known to smoke and required supervision and specific safety interventions, such as using an adaptive ashtray and wearing a smoking apron. However, the facility did not complete the required quarterly smoking evaluations, with the last evaluation being conducted in March 2023. This evaluation indicated that Resident #51 was unable to safely light, use an ashtray, or extinguish a cigarette, necessitating staff supervision and the use of a smoking apron. Observations revealed that Resident #51 was not using the adaptive ashtray as outlined in the care plan. On multiple occasions, the resident was seen smoking with a cigarette hanging from their mouth, without the use of the adaptive ashtray, and with ashes falling onto the smoking apron. Staff supervision was inadequate, as the supervising nurse was inside the building, and other residents were observed assisting Resident #51 by picking up dropped cigarettes. This lack of direct supervision and failure to use the adaptive ashtray posed a safety risk to the resident. Interviews with staff, including the Director of Nurses and the Staff Development Coordinator, confirmed that Resident #51 did not use the adaptive ashtray and preferred to smoke with the cigarette hanging from their mouth. The Director of Nurses acknowledged that the care plan was not being followed and that Resident #51's practice of keeping cigarettes in their room was against policy. The staff also recognized that Resident #51 required one-on-one supervision while smoking, which was not being provided, leading to the deficiency in ensuring a safe environment for the resident.
Failure in Foley Catheter Management and Follow-Up Care
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with an indwelling Foley catheter, which was not assessed for removal after the resident returned from a hospital stay. The resident, who had moderate cognitive impairment and a history of epilepsy, was hospitalized for seizures and returned with a Foley catheter due to acute urinary retention and urethral trauma. Despite discharge recommendations for a urology follow-up and a voiding trial, the facility did not document any attempts or discussions regarding these recommendations. The facility's records did not show a scheduled urology appointment, and the resident missed an appointment due to it not being logged or transportation arranged. Nursing staff were unaware of the appointment status, and the Director of Nurses acknowledged the oversight, indicating a need for process improvement. The resident experienced issues with the catheter, including leakage and discomfort, but there was no evidence of staff contacting the physician to discuss the voiding trial or follow-up care.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional status of a resident who experienced an unplanned gradual weight loss of 9.68% over six months. The resident, who was admitted with diagnoses including anoxic brain damage, dysphagia, and dementia, was identified as nutritionally at risk. Despite a care plan goal to maintain a weight of 185 pounds plus or minus 5 pounds, the resident's weight decreased from 169.4 pounds to 153 pounds over the specified period. The facility's Weight Management policy required residents to be weighed at least monthly, with more frequent weights as necessary, but the resident's weekly weights were not consistently obtained as ordered by the physician on 3/5/24. Interviews and record reviews revealed that the resident was not included on the list of those needing weekly weights, and the Registered Dietitian (RD) had not completed a quarterly assessment since March 2024. The RD, who began covering the facility in June 2024, was unaware of the resident's insidious weight loss until the week of the survey. The RD acknowledged the lack of a quarterly assessment and the failure to ensure weekly weights were obtained, which contributed to the oversight in monitoring the resident's nutritional status. The physician's progress notes also failed to recognize the significant weight loss, despite the resident's good meal intake.
Unnecessary Prolonged Use of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically Azithromycin, which was administered without an adequate indication for use for an excessive duration of one year. The resident, who was admitted with chronic respiratory failure, COPD, and pneumonia, was discharged from the hospital with a 5-day course of antibiotics for pneumonia. However, the discharge summary did not recommend long-term prophylactic antibiotic treatment. Despite this, the resident continued to receive Azithromycin three times a week for COPD without a documented indication for its prolonged use. The medical records lacked documentation from the pulmonologist or primary care physician justifying the need for long-term antibiotic use. Interviews with facility staff, including a nurse and the Director of Nurses, revealed that there was no clear documentation or rationale for the continued use of Azithromycin. The Director of Nurses attempted to contact the pulmonologist for clarification but was unable to provide additional documentation by the conclusion of the survey.
Failure to Adhere to Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered therapeutic diet was followed for a resident with significant medical conditions, including dysphagia, pneumonitis, and hemiplegia. The resident was assessed to be severely cognitively impaired and required a pureed diet with thin liquids for safe swallowing. Despite these orders, the surveyor observed the resident consuming crackers, which were not part of the prescribed diet. The resident's care plan indicated the need for tube feedings and pureed diet for pleasure foods, with supervision required during oral intake. Interviews with facility staff, including the Unit Manager, Director of Nursing, and Rehabilitation Director, revealed a lack of awareness and documentation regarding any exceptions to the resident's therapeutic diet. The Unit Manager acknowledged that staff would have had to assist the resident with the crackers, and the Rehabilitation Director confirmed that there was no documentation supporting the resident's ability to safely consume crackers unsupervised. The failure to adhere to the therapeutic diet was recognized as a risk for choking and aspiration, with no physician's order allowing for deviations from the prescribed diet.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident, leading to potential cross-contamination. The deficiency was observed during a wound care procedure performed by a nurse on a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not follow the facility's hand hygiene policy, which requires hand hygiene before and after glove changes and after contact with potentially contaminated surfaces. During the wound care procedure, the nurse removed soiled dressings and changed gloves multiple times without performing hand hygiene. The nurse also handled incorrect ointment tubes, touched the treatment cart, and continued the procedure without changing gloves or performing hand hygiene. Additionally, the nurse applied ointments directly from the tubes onto the resident's wound, which is against infection control practices. Interviews with the nurse and the Director of Nursing (DON) and Infection Preventionist/Staff Development (IP/SDC) confirmed the failure to adhere to hand hygiene protocols. The nurse admitted to not performing hand hygiene with every glove change and acknowledged the improper application of ointments. The DON and IP/SDC emphasized that hand hygiene should be performed with every glove change and that ointments should be applied to a clean surface before being used on wounds.
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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