Charlene Manor Extended Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Massachusetts.
- Location
- 130 Colrain Road, Greenfield, Massachusetts 01301
- CMS Provider Number
- 225304
- Inspections on file
- 27
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Charlene Manor Extended Care Facility during CMS and state inspections, most recent first.
A resident with a history of aggression and behavioral health issues was admitted for a short-term stay and repeatedly exhibited inappropriate and aggressive behaviors toward other residents, including a physical altercation. Despite documented incidents and staff awareness, the care plan did not include interventions or goals addressing these behaviors toward peers, nor did it document discharge planning, even though the resident expressed a desire to return to the community.
A resident with a history of Covid-19, chronic kidney disease, and heart failure experienced an unwitnessed fall, resulting in a head bump. The facility's policy required neurological checks at specific intervals, but these were not completed as documented on the Neurological Check Flowsheet. Interviews with nursing staff and the DON confirmed the failure to adhere to the protocol, leaving several checks unrecorded.
The facility failed to prevent and treat pressure ulcers for two residents. One resident was not repositioned or assisted out of bed due to a lack of Hoyer pads, leading to stage two pressure ulcers on the buttocks. The air mattress was not set correctly, and interventions were not implemented. Another resident developed a stage two pressure ulcer from a nasal cannula, which was not identified or treated promptly. The facility did not follow its skin integrity management policy, leading to deficiencies in care.
A resident with multiple medical conditions remained bedbound for over a week due to the unavailability of the correct Hoyer pad needed for safe transfers. The facility was aware of a shortage of Hoyer pads, which affected the resident's ability to get out of bed and increased their risk for discomfort and skin breakdown. Staff reported difficulties in finding the correct size Hoyer pad, and the facility's administration was not fully aware of the extent of the issue until it was highlighted by a surveyor.
The facility failed to provide adequate staffing on the Homestead Unit, resulting in delayed assistance with ADLs and meal distribution. A resident reported long waits for toileting help, while another resident with dementia and Parkinson's disease had unmet grooming needs. Meal distribution was delayed, with insufficient CNAs to serve meals promptly, and non-regular staff had to assist. Staff interviews confirmed frequent understaffing, impacting care for high-acuity residents.
The facility failed to maintain cleanliness and safety in the kitchenettes on the Meadows and [NAME] Units. The Meadows Unit had a broken refrigerator drawer, food debris, and a crumb-laden toaster, while the [NAME] Unit's toaster also had a buildup of crumbs. Staff were unclear about cleaning responsibilities, contributing to these deficiencies.
A facility failed to maintain resident dignity and privacy by not ensuring complete privacy during care procedures for a resident with MS and Cerebral Palsy, leaving them exposed to a public walkway. Additionally, CNAs were observed standing over residents while assisting with meals, despite instructions to sit, which could make residents feel uncomfortable.
The facility failed to notify physicians and resident representatives of condition changes for three residents. A resident experienced urinary catheter complications, another had a blister on the leg, and a third had multiple dental infections requiring antibiotics. In each case, there was a lack of timely communication with the physician or the resident's representative, leading to delays in care and treatment.
A facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's Health Care Proxy (HCP) when the resident lacked capacity due to dementia. The NOMNC was incorrectly signed by the resident, and the SNF ABN was not issued, leaving the HCP uninformed of potential financial liabilities. This was confirmed by MDS Nurse #1 during a review.
Two residents in an LTC facility were found to be inappropriately restrained without proper assessment or documentation. One resident was unable to exit the bed due to unassessed side rails, while another had wedge cushions and a bed against the wall, impeding movement. Staff acknowledged these setups as restraints, which were not consented to or documented, violating facility policies.
A facility failed to provide necessary documentation to a hospital when a resident was transferred due to unmet medical needs. The resident had symptoms including a high temperature and was transferred on a physician's order. However, the facility did not complete the required SBAR assessment, omitting essential information such as physician contact details and care instructions, leading to a deficiency in ensuring a safe transition of care.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required. The resident, admitted with a fall and a hip fracture, had an incomplete baseline care plan lacking initial goals. The resident's clinical record did not show a comprehensive care plan, and the resident was transferred to the hospital after more than 48 hours. The social worker acknowledged the oversight, citing the resident's short stay as a reason.
The facility failed to ensure care plans were reviewed and revised by the IDT and included residents or their representatives for three residents. A resident's care plan meetings lacked documentation of attendance and discussion, another resident's care plan was not reviewed after an MDS assessment, and a third resident's care plan was not revised following two MDS assessments. The social worker acknowledged these oversights, indicating lapses in scheduling and documentation processes.
Two residents with severe cognitive impairments did not receive necessary grooming assistance as per their care plans. Despite being dependent on staff for personal hygiene, both residents were observed with unremoved facial hair. Staff interviews revealed that time constraints and staffing issues contributed to the failure to provide consistent grooming care.
A resident with severe cognitive impairment and dependency on staff for daily activities developed a fluid-filled blister on the right lower leg. The facility failed to assess the cause, notify the physician, and obtain treatment orders in a timely manner, as required by their policy. The blister was identified on October 31, but the physician was not notified, and treatment orders were not obtained until November 4, increasing the risk of further skin decline and infection.
A resident with a history of Peripheral Vascular Disease (PVD) and a recent below-the-knee amputation was not offered podiatry services upon admission, despite the facility's policy to provide consulting services when needed. The resident expressed concern about foot health, and observations revealed dry skin, long toenails, and a reddened area on the leg. Both the resident and a nurse acknowledged the need for podiatry services, but the Director of Admissions found no documentation that such services were offered.
A resident with severe cognitive impairment and COPD was allowed to keep an Albuterol inhaler on the bedside table without proper assessment or supervision. The facility's policy required an assessment for self-administration, which was not conducted, and staff were uncertain about the resident's ability to manage the inhaler safely. The inhaler was eventually removed by a nurse, acknowledging the oversight.
A resident with a chronic indwelling Foley catheter experienced urinary leakage, and the facility failed to provide timely treatment. The resident did not attend a scheduled urology appointment, and staff did not follow hospital discharge instructions. Despite 24-hour physician coverage, the facility lacked specific orders for managing catheter complications, leading to a delay in replacing the leaking catheter.
A resident with significant weight loss was not reweighed weekly as recommended by the Dietitian. Despite multiple requests, the facility failed to obtain the necessary weights or document reasons for non-compliance. The Unit Manager was unable to check emails due to staffing issues, resulting in the Dietitian's recommendations not being implemented.
A resident with cerebral palsy and severe cognitive impairment was observed with bed rails positioned in the upward half-rail position, contrary to the physician's order for quarter-size rails. Facility staff, including CNAs and the Unit Manager, were unaware of the correct positioning, and the DON confirmed that the resident had not been assessed for the use of half rails, highlighting a failure to adhere to the facility's policy and physician's orders.
A facility failed to ensure that all licensed nurses had the appropriate competencies for indwelling urinary catheter care, impacting a resident with obstructive uropathy and a chronic Foley catheter. Nurse #5 observed urinary leakage but was unfamiliar with the catheter placement and did not obtain physician orders, resulting in delayed treatment. The facility's assessment indicated staff competency in such care, but Nurse #5's competency was not assessed, and she did not contact the on-call physician despite 24-hour coverage. The Staff Development Coordinator admitted that competency assessments were not routinely completed.
A resident with chronic pain syndrome and opioid dependence received an excessive dose of Oxycodone due to a nurse administering a 10 mg dose intended for severe pain, despite the resident reporting moderate pain. The nurse did not follow the physician's orders, which specified a 5 mg dose for moderate pain, and did not seek approval to deviate from the prescribed dosage.
A resident with a history of atrial fibrillation and a prosthetic heart valve experienced a significant medication error when Vitamin K was administered without a physician's order, leading to sub-therapeutic INR levels. The error occurred due to an incorrect entry in the electronic medical record, resulting in multiple doses being given instead of a single dose. The resident's representative expressed concerns about the management of the resident's anticoagulant therapy and the facility's tracking of INR levels.
The facility failed to provide necessary dental services for two residents, leading to deficiencies in their care. One resident, with dementia and dysphagia, missed scheduled dental evaluations despite being enrolled in services. Another resident, also with dementia, experienced mouth pain and required antibiotics, but had no documented consent or evaluation for dental services since admission. The facility did not follow up on dental service consent, resulting in inadequate care.
The facility failed to adhere to infection control standards for two residents. One resident's over-bed table was not cleaned after a used urinal was placed on it, and food was subsequently served on the uncleaned table. Another resident's urinary catheter drainage bag was found on the floor, and staff did not wear gowns as required by Enhanced Barrier Precautions. These actions indicate a lapse in following infection prevention protocols.
The facility failed to offer a second dose of the 2023-2024 COVID-19 vaccine to three eligible residents, despite CDC recommendations. The residents, who had received one dose, did not have documentation indicating a second dose was offered. The Regional Infection Preventionist confirmed the oversight, noting the facility's updated consent forms should have facilitated the offering of the additional dose.
The facility failed to post complete daily nurse staffing information, omitting details such as the facility census and total hours for RNs, LPNs, and CNAs. The report only showed the number of licensed and unlicensed staff. The Scheduler responsible for posting was unaware of the specific requirements, leading to this deficiency.
The facility failed to complete Significant Change in Status Assessments (SCSA) for a resident who experienced a decline in memory, ADLs, and bowel and bladder function, and for two residents admitted to Hospice services. Despite significant changes in their conditions, the required assessments were not conducted, as confirmed by the MDS Nurse.
A facility failed to accurately complete the MDS Assessment for a resident by not selecting the 'Indication Noted' box for antipsychotic and antidepressant medications, despite the resident having relevant diagnoses. The Regional MDS Nurse confirmed the inaccuracy, acknowledging that the MDS was coded incorrectly.
The facility failed to maintain a safe, clean, and homelike environment, with surveyors observing disrepair and unclean conditions in resident areas. Issues included buckled carpeting, stained furniture, and chipped woodwork. Staff and family members confirmed these concerns, and the Director of Environmental Services admitted to the lack of a maintenance plan. The facility's policies were not effectively implemented, and there was no documentation of a plan to address the deficiencies.
The facility's QAPI program failed to ensure a clean and safe environment, with significant deficiencies observed in the physical environment, such as worn carpets, scratched doors, and trip hazards. The Director of Environmental Services was often absent from QAPI meetings, and there was no maintenance plan for addressing wear and tear in resident areas.
Failure to Address Resident-to-Resident Aggression and Discharge Planning in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically regarding aggressive and inappropriate behaviors toward other residents and discharge planning. The resident, admitted for a short-term stay with diagnoses including congestive heart failure, diabetes mellitus, and bipolar disorder, exhibited both physical and verbal behavioral symptoms directed at others, as documented in the Minimum Data Set (MDS) assessments and nursing notes. Despite multiple incidents of inappropriate comments, derogatory language, and physical altercations with other residents, the care plan did not include interventions or goals specific to these behaviors toward fellow residents. Facility records and staff interviews revealed that the resident frequently disrupted common areas and mealtimes with aggressive verbal behavior, which was difficult for staff to redirect and often led to other residents avoiding communal activities. A significant incident involved the resident physically striking another resident with a remote control, resulting in injury and necessitating behavioral health evaluation. The care plan, however, only addressed interactions with staff and did not reflect the resident's history of resident-to-resident altercations or the need for targeted interventions to manage these behaviors. Additionally, the care plan lacked documentation of discharge planning, despite the resident's stated goal to return to the community and ongoing efforts by social services and case management to identify appropriate placement. Staff interviews confirmed that no formal discharge plan was in place, and the care plan was not updated to reflect the resident's preferences or potential for discharge. The Director of Nursing acknowledged that the care plan should have included both behavioral interventions for resident-to-resident issues and a plan for transitioning the resident out of the facility.
Incomplete Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who sustained an unwitnessed fall. According to the facility's policy on Falls Management: Post Fall, neurological checks should be conducted at specific intervals following an unwitnessed fall or a fall involving a head injury. The resident, who had a history of Covid-19, chronic kidney disease stage 4, and acute diastolic heart failure, was found to have a small bump on the back of the head after the fall. However, the neurological checks were not performed as required by the policy. The checks were initiated but not completed at the specified intervals, leaving several time slots on the Neurological Check Flowsheet blank. Interviews with nursing staff and the Director of Nursing confirmed the failure to complete the neurological assessments as per the facility's policy. Nurse #2 acknowledged documenting some assessments but admitted to not completing others without a clear reason. Nurse #1 and the Admission Nurse both confirmed the importance of these checks in identifying potential brain injuries and noted the incomplete documentation. The Director of Nursing also reviewed the Flowsheet and confirmed it was incomplete, indicating a lapse in following the established protocol for post-fall assessments.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent and treat pressure ulcers for two residents. For one resident, the facility did not offload pressure on the buttocks, provide repositioning, or assist the resident out of bed daily as per the care plan. The resident complained of discomfort and had not been out of bed for over a week due to the unavailability of a Hoyer pad. Observations revealed redness and open areas on the resident's buttocks, indicating stage two pressure ulcers. The air mattress was not set according to the resident's weight, potentially contributing to skin breakdown. The facility did not implement interventions or notify the wound nurse and physician promptly. Another resident developed a stage two pressure ulcer on the philtrum and base of the nostrils due to the use of a nasal cannula. The facility failed to complete skin assessments and identify the pressure ulcer in a timely manner. The resident reported pain, and the open area was observed by the surveyor. The nursing staff did not notice the skin condition during care, and there were no progress notes or treatment orders for the open area. The wound nurse confirmed the stage two pressure ulcer resulted from the nasal cannula tubing. The facility's policy on skin integrity management was not followed, as residents did not receive care consistent with professional standards to prevent and treat pressure ulcers. The facility failed to assess and document skin conditions, implement necessary interventions, and notify medical practitioners promptly. The lack of appropriate equipment and failure to adhere to care plans contributed to the development and worsening of pressure ulcers in the residents.
Hoyer Pad Shortage Leads to Resident Remaining Bedbound
Penalty
Summary
The facility failed to provide an appropriate sized Hoyer pad for a resident, resulting in the resident remaining bedbound for over a week. The resident, who has multiple medical conditions including Multiple Sclerosis, Type 2 Diabetes, and Cerebral Palsy, expressed a desire to get out of bed but was unable to do so due to the unavailability of the correct Hoyer pad. The resident's care plan indicated the need for a specific Hoyer pad for safe transfers, but the pad was not available, leading to the resident experiencing discomfort and an increased risk for skin breakdown. Interviews with staff revealed that there was a shortage of Hoyer pads in the facility, and staff often had to search other units or the laundry to find the correct size. The issue was known to the facility management, but there were still not enough Hoyer pads to meet the needs of all residents requiring them. Staff reported that the lack of Hoyer pads sometimes resulted in residents missing scheduled showers or remaining in bed, as was the case with the resident in question. The facility's administration was not fully aware of the extent of the Hoyer pad shortage until it was brought to their attention by the surveyor. The Director of Nursing acknowledged that audits for Hoyer pads were supposed to be conducted quarterly, but these audits had not been completed. The lack of communication and oversight contributed to the deficiency, as the resident's need for a specific Hoyer pad was not consistently met, impacting their care and comfort.
Staffing Deficiencies Impact Resident Care and Meal Distribution
Penalty
Summary
The facility failed to provide sufficient staffing on the Homestead Unit, leading to unmet needs for residents' Activities of Daily Living (ADL). A resident reported that assistance with toileting needs was delayed, sometimes taking hours after ringing the call bell. This inconsistency in response times was noted to vary across different shifts. Another resident, admitted with dementia and Parkinson's disease, was observed to have unmet grooming needs, such as facial hair removal and personal hygiene, despite being dependent on staff for these tasks. The resident's representative expressed concerns about the lack of regular care, including the cleaning of dentures and application of lotion for dry skin. During meal times, the facility also demonstrated insufficient staffing, impacting the timely distribution of meals. On one occasion, the breakfast meal cart arrived at the unit, but there was a delay of 44 minutes before all residents received their meals. Initially, only one CNA was available to pass trays to 17 residents, with additional staff joining later. On another day, corporate clinical staff and other non-regular staff assisted with meal distribution, which was not typical practice, indicating a lack of regular staff to manage meal times effectively. Interviews with staff revealed that the Homestead Unit was often understaffed, with fewer CNAs than required for both the morning and evening shifts. A nurse confirmed that the unit had high-acuity residents needing intensive care, and the staffing levels were inadequate to meet these needs. The nurse also acknowledged the issues with meal distribution and the lack of sufficient staff to ensure residents were served meals simultaneously.
Deficiencies in Kitchenette Cleanliness and Safety
Penalty
Summary
The facility failed to maintain cleanliness and safety in the unit kitchenettes on the Meadows Unit and the [NAME] Unit. On the Meadows Unit, the refrigerator had a broken and missing crisper drawer, and food debris was observed on the inside shelves and floor of the refrigerator. A dirty plate was left on top of the refrigerator, and the toaster was heavily laden with crumbs, posing a fire risk. Housekeeping Staff #2 acknowledged the toaster had not been cleaned recently and that dirty dishes should be removed daily. The Food Services Director stated it was housekeeping's responsibility to clean the refrigerators, while the Environmental Services Director noted that no staff had reported the broken refrigerator equipment. The Administrator confirmed there was no written protocol for cleaning responsibilities in the kitchenettes. On the [NAME] Unit, the toaster was observed to have a buildup of crumbs, which Dietary Staff #1 identified as a concern for cross-contamination and a fire hazard. The lack of a clear protocol for cleaning responsibilities contributed to the deficiencies observed in both units, with staff unsure of their specific duties regarding the maintenance and cleanliness of the kitchenettes.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident during care procedures. Specifically, a nurse did not ensure complete privacy for a resident with Multiple Sclerosis and Cerebral Palsy while assessing and providing care to the resident's buttocks. Although the privacy curtain was pulled between the resident's bed and their roommate's bed, it was not pulled between the resident's bed and a window facing a public walkway. This oversight left the resident's exposed buttocks visible to the outside, compromising their privacy. Additionally, the facility did not ensure that staff maintained a dignified approach while assisting residents during meals. Certified Nurses Aides were observed standing over residents while assisting them with their meals in the dining room, despite being instructed by the Director of Nursing to sit. This practice was acknowledged by the staff as inappropriate, as it could make residents feel uncomfortable and undermine their dignity.
Failure to Notify Physicians and Representatives of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and/or responsible party of a change in condition for three residents. Resident #2 experienced complications with an indwelling urinary catheter, which was leaking. Despite the presence of a Foley catheter, urine was found in the resident's incontinence brief, indicating a malfunction. Nurse #5, who was on duty during the weekend, did not contact the physician due to the absence of specific orders and instead left a note in the Physician Communication Book. This resulted in a delay in addressing the issue until the following day when Nurse #2 contacted the physician and obtained the necessary orders to flush and replace the catheter. Resident #88 had a blister identified on the inner leg by a CNA, but there was no documented evidence that the physician or the resident's representative was notified. The blister was discovered on a Thursday evening, and by the following Monday, neither the physician nor the resident's representative had been informed. Nurse #1 and Unit Manager #1 were unaware of the blister until it was brought to their attention during the survey, indicating a lapse in communication and documentation. Resident #43 experienced multiple dental infections requiring antibiotic treatment, but there was no documented evidence that the resident's representative was informed of these medical issues. The resident received several courses of antibiotics for mouth and tooth pain, yet the representative was not made aware of these treatments. Unit Manager #1 confirmed the lack of notification to the resident's representative, highlighting a failure in communication regarding the resident's change in condition.
Failure to Issue Proper Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) were properly issued for a resident who was receiving benefits under Medicare Part A. Specifically, the NOMNC was not issued to the resident's Health Care Proxy (HCP) when the resident was determined to lack the capacity to make medical decisions due to dementia. Instead, the NOMNC was signed by the resident, which was inappropriate given the documented incapacity. Additionally, the facility did not issue the SNF ABN to the resident's HCP, which would have informed them of the potential financial liability for services that may not be covered by Medicare. This oversight occurred when the resident's Medicare benefits ended, and the facility was unable to provide any SNF ABN notice for review. The failure to issue these notices was confirmed during an interview with MDS Nurse #1, who acknowledged that the notices should have been issued to the HCP based on the resident's incapacity.
Inappropriate Use of Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, which were not medically necessary and not properly assessed or documented. For one resident, the facility did not assess the use of bilateral half middle side rails, which were not the quarter side rails ordered by the physician. These side rails prevented the resident from exiting the bed, and the resident expressed a desire to get out of bed but was unable to do so due to the side rails. The staff, including a nurse and a certified nurse aide, acknowledged that the side rails were used to keep the resident in bed, which could be considered a restraint. Another resident was found to have wedge cushions placed under the fitted sheet on one side of the bed, with the other side of the bed positioned against the wall. This setup was used to prevent the resident from falling out of bed, but it also impeded the resident's ability to exit the bed, effectively acting as a restraint. The unit manager was unaware of the use of these wedge cushions and acknowledged that they should not have been used without proper assessment and consent. The facility's policies on restraint management and side rails require that any use of restraints be assessed, documented, and consented to by the resident or their representative. However, in both cases, these procedures were not followed, leading to the inappropriate use of restraints without proper assessment or documentation. This oversight put the residents at potential risk of harm and did not comply with the facility's own policies or regulatory requirements.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to provide the necessary documentation to the receiving hospital when a resident was transferred due to unmet medical needs. The resident, who was admitted in May 2024, experienced discomfort and multiple episodes of non-productive coughing, with a recorded temperature of 103.1 degrees axillary. Following these symptoms, the on-call physician ordered the resident's transfer to the hospital. However, the clinical record lacked evidence that essential information, such as the contact information of the resident's physician, resident representative details, advanced directive information, special instructions for ongoing care, and comprehensive care plan goals, was provided to the hospital. During an interview, the social worker confirmed that the facility staff were required to complete an SBAR assessment, which includes all necessary information for the receiving hospital. Upon reviewing the resident's clinical record, the social worker noted that the SBAR was not completed for the resident's transfer, and there was no evidence that the required information was communicated to the hospital. This oversight resulted in a deficiency related to the facility's failure to ensure a safe and effective transition of care for the resident.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted in May 2024, had diagnoses including an unspecified fall and a displaced intertrochanteric fracture of the right femur. The baseline admission care plan for the resident included basic information such as the date of birth, date of admission, medical history, and physician's contact information. However, it lacked completion in other sections and did not include any initial goals for the resident. The clinical record of the resident did not show evidence of a comprehensive care plan being developed in place of the baseline care plan. A nursing progress note indicated that the resident was transferred to the hospital more than 48 hours after admission. During interviews, the social worker acknowledged that the baseline care plan was not completed, attributing it to the resident's short stay at the facility. The social worker also mentioned that nursing staff were responsible for completing baseline care plans upon admission.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT) and included the resident and/or their representative for three residents out of a sample of 25. Specifically, the facility did not provide evidence that Resident #17 and/or their representative were invited to or attended two separate care plan meetings. Additionally, there was no documentation of which facility staff attended these meetings. For Resident #92, the facility did not review and revise the care plan following a Minimum Data Set (MDS) assessment. The social worker acknowledged that the care plan meeting for Resident #92 did not occur due to human error. This oversight indicates a lapse in the facility's process for ensuring timely and comprehensive care plan reviews. Resident #88's care plan was not reviewed and revised following two separate MDS assessments. The facility's records lacked documentation of care plan meetings after the assessments, and there was no evidence of what was discussed or who attended the meetings. The social worker confirmed that the care plan meeting for Resident #88 was missed after one of the assessments, highlighting a failure in the facility's scheduling and documentation processes.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents, both of whom were dependent on staff for personal hygiene due to severe cognitive impairments. Resident #88, diagnosed with dementia and Parkinson's disease, was observed multiple times with facial hair despite a care plan indicating the need for daily grooming assistance. The resident's representative confirmed the resident's preference for a clean-shaven appearance, which was not maintained. Interviews with staff revealed that although the resident did not refuse care, the grooming task was not completed due to time constraints and staffing issues. Similarly, Resident #43, also with severe cognitive impairment, was observed with long facial hair despite being receptive to grooming assistance. The care plan required staff assistance for grooming, yet observations indicated that the resident's facial hair was not consistently removed. Staff interviews confirmed that while the resident could partially groom with an electric razor, they required staff assistance to complete the task, which was not consistently provided. Both residents had documented care plans that specified the need for staff assistance with grooming, yet observations and interviews indicated that these needs were not met consistently. The facility's failure to adhere to the care plans and provide adequate grooming assistance resulted in the residents not receiving the personal hygiene care they required, as evidenced by the repeated observations of unremoved facial hair.
Delayed Assessment and Treatment of Resident's Skin Blister
Penalty
Summary
The facility failed to provide timely assessment and treatment for a skin issue identified in a resident. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was found to have a fluid-filled blister on the right lower leg. Despite the facility's policy requiring prompt notification and treatment for skin issues, the blister was not assessed for its cause, and the physician and responsible party were not notified in a timely manner. The deficiency was observed when a Certified Nurses Aide (CNA) reported the blister to a nurse, who applied a protective dressing but did not obtain treatment orders or notify the physician immediately. The blister was first identified on October 31, but it was not until November 4 that the physician was notified, and treatment orders were obtained. This delay in notification and treatment increased the risk of further skin decline and infection for the resident. Interviews with staff revealed that the Unit Manager and Wound Nurse were not informed of the blister until several days after its discovery. The facility's policy on skin integrity management was not followed, as evidenced by the lack of timely incident reporting, physician notification, and treatment order acquisition. The resident's clinical record showed no documentation of physician notification or treatment orders until four days after the blister was initially reported.
Failure to Offer Podiatry Services to Resident with PVD
Penalty
Summary
The facility failed to offer assistance in scheduling an appointment for podiatry services to a resident who was at risk for a decline in foot health due to a history of Peripheral Vascular Disease (PVD) and a recent below-the-knee amputation. The resident, admitted in September 2024, expressed concern about a reddened area on the lower left leg and the condition of the left foot, which was observed to be dry with large patches of flaking skin, long and hardened toenails, and dirt under the nails. The resident reported not being offered podiatry services since admission, despite the facility's policy indicating that consulting services should be provided upon admission or when needed. During observations and interviews, both the resident and Nurse #4 acknowledged the need for podiatry services, especially given the resident's medical history. Nurse #4 confirmed the importance of good foot health for residents with PVD and noted that the resident's toenails required trimming. The Director of Admissions admitted that the resident should have been offered podiatry services at admission and found no documentation to indicate that such services had been offered. This oversight highlights a deficiency in the facility's adherence to its policy on consulting services.
Inhaler Mismanagement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was free from potential accidental hazards by allowing the resident to store an Albuterol Sulfate inhaler on the bedside table and use it without proper assessment or supervision. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had severe cognitive impairment, was observed with the inhaler easily accessible on multiple occasions. The facility's policy required medications to be administered safely and for residents to be assessed for their ability to self-administer medications, which was not done in this case. The resident's November 2024 Physician's orders indicated the use of the inhaler as needed for COPD, but there was no documented evidence of the resident being assessed for self-administration or any record of the inhaler being administered by staff. Interviews with facility staff revealed uncertainty about the resident's ability to have the inhaler at the bedside and highlighted the potential danger of leaving medication unattended, especially given the resident's memory impairment. The inhaler was eventually removed by a nurse, acknowledging that the resident should not have had unsupervised access to it.
Failure to Manage Indwelling Urinary Catheter Complications
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter, leading to increased risk of complications and delayed treatment. The resident, who was admitted with diagnoses including dementia and chronic indwelling Foley catheter, was supposed to attend a follow-up appointment with a urologist, which did not occur. The facility staff did not follow hospital discharge instructions, and there was no evidence that the resident attended the scheduled urology appointment. The resident experienced urinary leakage outside of the indwelling urinary catheter system, a complication that can occur when a catheter becomes dislodged or obstructed. Despite this, the facility staff failed to consult a physician promptly. The nursing progress notes indicated that the resident's catheter was leaking, and there were no physician orders specifying the type or size of the catheter needed for replacement. The weekend supervisor did not take immediate action, and the issue was only addressed the following day after contacting the on-call physician. The Director of Nursing confirmed that the facility has 24-hour physician coverage and that orders for managing catheter complications should have been obtained upon the resident's admission. The lack of timely intervention and appropriate physician orders resulted in a delay in replacing the leaking catheter, which was only addressed after the resident experienced discomfort and further complications.
Failure to Implement Dietitian's Recommendations for Weight Monitoring
Penalty
Summary
The facility failed to follow the recommendations made by the Dietitian for a resident who experienced a significant weight loss of 13.44% over five months. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes, Dementia, Dysphagia, and Adult Failure to Thrive, was not reweighed weekly as recommended by the Dietitian. Despite multiple requests from the Dietitian for a reweigh to verify the resident's weight loss, the facility did not obtain the necessary weights or provide documentation explaining the failure to do so. The Dietitian had communicated the need for weekly weights through emails to the Unit Manager and the Director of Nursing, but these requests were not acted upon. The Unit Manager cited an inability to check emails due to being reassigned to work the medication cart, leaving no one to cover her usual responsibilities. As a result, the Dietitian's recommendations were not implemented, and the resident's weight was not monitored as required, leading to a deficiency in the facility's care for the resident.
Improper Use of Bed Rails for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure the correct use of bed rails for a resident, who was admitted with conditions including cerebral palsy, a wound of the foot, and memory deficit. The resident was assessed as severely cognitively impaired and required assistance for mobility. The physician had ordered quarter-size side rails for the resident, but observations revealed that the facility staff positioned the bed rails in the upward half-rail position along the middle of the bed, contrary to the physician's orders. The facility's policy on side rails, which requires an assessment of the resident's mobility and cognitive functioning, was not adhered to. The resident's nursing admission assessment indicated the use of quarter upper rails was appropriate, and the side rails were not considered a restraint. However, the staff positioned the side rails in a manner that was not assessed or ordered, potentially increasing the resident's risk for limited mobility and injury. Interviews with facility staff, including CNAs and the Unit Manager, revealed a lack of awareness and adherence to the assessed and ordered use of side rails. The CNAs believed the half-rail position helped the resident with mobility and security, but the Unit Manager and DON confirmed that the resident had not been assessed for the use of half rails, and the physician's order for quarter rails was not followed. The DON acknowledged that a reassessment should have been completed if the resident required a different use of side rails.
Failure in Indwelling Urinary Catheter Care Competency
Penalty
Summary
The facility failed to ensure that all licensed nurses had the appropriate competencies for indwelling urinary catheter care, specifically impacting one resident with obstructive uropathy and a chronic Foley catheter. The deficiency was identified when Nurse #5, responsible for the resident's care, observed urinary leakage from the catheter but was unfamiliar with the catheter placement and did not obtain physician orders to address the issue. This resulted in delayed treatment and increased the risk of further complications for the resident. The facility's assessment indicated that staff were deemed competent in caring for residents with genitourinary conditions, including those requiring indwelling catheters. However, Nurse #5 was not assessed for competency in this area, as evidenced by the lack of documentation in her competency assessments. The resident's care plan required catheter changes if the system was interrupted and physician notification for complications, but Nurse #5 did not follow these protocols due to a lack of familiarity and absence of specific physician orders. Interviews revealed that Nurse #5 did not contact the on-call physician when the leakage was observed, despite the facility having 24-hour physician coverage. The Staff Development Coordinator acknowledged that competency assessments for indwelling catheter care were not routinely completed, particularly for nurses on units where such cases were infrequent. This oversight contributed to the delay in addressing the resident's catheter complications.
Improper Oxycodone Administration for Moderate Pain
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drug administration, specifically regarding the administration of Oxycodone, a highly addictive opioid medication. The deficiency occurred when the facility did not adhere to the physician's orders for Oxycodone dosage and pain scale parameters, resulting in the resident receiving an excessive dose. The resident, who was admitted with chronic pain syndrome and opioid dependence, reported moderate pain, but was administered a dose intended for severe pain. The resident's physician orders specified that a 5 mg dose of Oxycodone should be administered for moderate pain (4-7/10) and a 10 mg dose for severe pain (8-10/10). However, on the day of the incident, a nurse administered a 10 mg dose despite the resident reporting a pain level of 5/10, which is classified as moderate pain. The nurse did not obtain instructions from the physician or nurse practitioner to deviate from the prescribed dosage parameters. Interviews with the nurse and the regional quality improvement nurse confirmed that the medication was not administered according to the physician's orders. The nurse acknowledged administering the higher dose because the resident expressed dissatisfaction with the lower dose and requested the 10 mg dose. The regional quality improvement nurse emphasized that medications should be administered according to the physician's orders and the resident's reported pain level.
Significant Medication Error with Vitamin K Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a dose of Vitamin K was administered without a physician's order, resulting in sub-therapeutic laboratory levels. The resident, who had a history of atrial fibrillation, hypertension, a cardiac pacemaker, and a prosthetic heart valve, was at risk for bleeding due to anticoagulant therapy. The resident's INR levels were critically high, prompting a physician's order to hold Coumadin and administer a one-time dose of Vitamin K. However, the order was incorrectly entered into the electronic medical record without a stop date, leading to the resident receiving multiple doses of Vitamin K. This error was identified during a review of the medication administration record, which showed that Vitamin K was administered on two consecutive days instead of just once. The resident's representative expressed concerns about the management of the resident's Coumadin therapy and the facility's tracking of INR levels. Interviews with the unit manager confirmed that the resident received two doses of Vitamin K instead of one, which was considered a significant medication error. The unit manager acknowledged that the nurse entered the order incorrectly, resulting in the continued administration of Vitamin K. The resident's representative was worried about the potential harm to the resident due to the medication error and had difficulty obtaining information from the nursing staff about the resident's INR levels and Coumadin doses.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide necessary dental services for two residents, leading to deficiencies in their care. Resident #88, who was admitted with diagnoses including dementia and dysphagia, required assistance with oral hygiene and was dependent on staff for eating. Despite being enrolled in dental services, the resident had not been evaluated by a dental hygienist or dentist since March 2023, missing scheduled visits in September 2023 and March 2024. The resident's representative expressed a desire for regular bi-annual dental visits, but there was no documented evidence of consent or declination for dental services in the resident's clinical record. Resident #43, also diagnosed with dementia, experienced mouth and tooth pain, requiring antibiotic treatment. Despite complaints and a history of severe cognitive impairment, there was no documented evidence of consent or evaluation for dental services since the resident's admission in September 2020. The resident's representative had agreed to dental services about a year ago, but the facility failed to follow up and ensure these services were provided. The Accounts Payable Staff discovered that the section for dental services consent on the admission form was left blank, indicating a lack of proper documentation and follow-up by the facility staff.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards, resulting in potential transmission risks for two residents. For Resident #108, the over-bed table was not cleaned and disinfected after a used urinal was placed on it. This oversight occurred despite the facility's policy requiring cleaning of the over-bed table before meals. The surveyor observed multiple staff members, including a CNA, a nurse, and the Activities Director, placing food and drinks on the uncleaned table. Interviews with staff confirmed the expectation that the table should have been cleaned, highlighting a lapse in infection control practices. For Resident #2, the facility did not maintain the indwelling urinary catheter off the floor, as required by infection control protocols. The catheter collection drainage bag was observed lying on the floor, which is against the facility's Enhanced Barrier Precautions (EBP) policy. Despite the presence of EBP signage indicating the need for gown and glove use during high-contact activities, CNAs assisting the resident did not wear gowns while handling the catheter and transferring the resident. Interviews with the CNAs and the Unit Manager confirmed the expectation that the catheter should not be on the floor and that gowns should be worn during such activities. These deficiencies indicate a failure to follow established infection control policies, potentially increasing the risk of infection transmission. The staff's actions and inactions, as observed and confirmed through interviews, demonstrate a lack of adherence to the facility's infection prevention protocols, particularly concerning the cleaning of surfaces and the handling of medical devices.
Failure to Offer Second Dose of COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to provide evidence that updated COVID-19 vaccines were offered to three residents, increasing their risk for illness. Specifically, the facility did not offer a second dose of the 2023-2024 COVID-19 vaccine to three residents, despite the CDC's Advisory Committee on Immunization Practices (ACIP) recommending an additional dose for older adults. The residents had received one dose of the 2023-2024 vaccine, but there was no documentation indicating that a second dose was offered, as required by national standards. Resident #5, who was admitted in November 2019 with diagnoses including Multiple Sclerosis and Dementia, received one dose of the 2023-2024 COVID-19 vaccine in November 2023. However, there was no evidence that a second dose was offered four months later, as recommended. Similarly, Resident #92, admitted in May 2023 with Dementia and Stage Four Chronic Kidney Disease, received one dose in October 2023, but there was no documentation of a second dose being offered. Resident #61, admitted in November 2023 with Dementia and a history of Pulmonary Embolism, also received one dose in November 2023, with no evidence of a second dose being offered. The Regional Infection Preventionist confirmed that the facility had updated their vaccine consent forms to include consent for current and future vaccines, eliminating the need for new consent each time. Despite this, the facility did not offer the second dose of the 2023-2024 COVID-19 vaccine to the eligible residents. The Infection Preventionist acknowledged the oversight and noted that there was no evidence of the second dose being offered to the residents before the availability of the 2024-2025 vaccine.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. The deficiency was observed on multiple occasions, where the daily staffing report was posted on the door of the front office next to the facility lobby. However, the report did not include essential details such as the facility census, the total number and hours for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), and the total hours for Certified Nurse Aides (CNAs). Instead, the report only indicated the number of licensed and unlicensed staff, which does not meet the regulatory requirements. During an interview, the facility Scheduler, who is responsible for updating and posting the staff report daily, admitted to not being familiar with the specific posting requirements. The Scheduler confirmed that the information for licensed nursing staff was combined for RNs and LPNs, and the unlicensed staff information was represented by the number of CNAs. The lack of familiarity with the requirements led to the omission of critical staffing data, resulting in the deficiency.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete Significant Change in Status Assessments (SCSA) for three residents who experienced significant changes in their conditions. Resident #104 experienced a decline in memory, activities of daily living (ADLs), and bowel and bladder function, as evidenced by a decrease in the Brief Interview of Mental Status (BIMS) score from 15 to 9, indicating moderate cognitive impairment, and the need for an indwelling urinary catheter and colostomy. Despite these changes, the facility did not complete a SCSA for Resident #104, as confirmed by the MDS Nurse during an interview. Additionally, the facility did not complete SCSAs for Residents #84 and #88 when they were admitted to Hospice services. Resident #84 was admitted to Hospice services, but no SCSA was completed within the required 14 days. Similarly, Resident #88, who had severe cognitive impairment, was referred to Hospice services following a significant weight loss and was admitted to Hospice care, but the facility failed to complete a SCSA. The MDS Nurse acknowledged the oversight for both residents during interviews.
Inaccurate MDS Assessment for Medication Indication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessments for a resident, specifically in coding the indication for the use of antipsychotic and antidepressant medications. The resident, who was admitted with diagnoses including Dementia with Psychotic Disturbance and Anxiety, was prescribed Lexapro for Anxiety and Seroquel for Dementia with Psychotic Disturbance. During the review of the resident's Medication Administration Record (MAR) for October 2024, it was noted that the resident received both medications as ordered on six out of seven days within the lookback period. However, the MDS assessment did not have the 'Indication Noted' box selected for either the antipsychotic or antidepressant medication use, despite the resident having the relevant diagnoses. This oversight was confirmed during an interview with the Regional MDS Nurse, who acknowledged that the MDS was coded inaccurately and that the indication for both medications should have been noted. This inaccuracy in the MDS assessment represents a deficiency in ensuring accurate resident assessments.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey. The surveyors noted various stages of disrepair, aging, and unclean conditions in common areas, resident rooms, and care areas. Specific issues included buckled and torn carpeting, heavily stained and soiled furniture, chipped and splintered woodwork, peeling wallpaper, and exposed screws, all of which posed potential hazards to residents. These conditions were observed across multiple units, including the Meadows Rehabilitation Unit, the Dementia Specialty Care Unit, and common areas such as hallways and elevators. Interviews with staff and family members corroborated the surveyors' findings. Family members and residents expressed concerns about the cleanliness and state of disrepair in the facility, noting that the environment appeared run down and in need of significant improvements. Staff members, including a CNA and the Director of Environmental Services, acknowledged the longstanding issues with the facility's carpeting and curtains, and the lack of a systematic approach to address wear and tear in resident areas. The Director of Environmental Services admitted to the absence of a comprehensive maintenance plan and documentation to support requests for necessary repairs and replacements. The facility's policies and procedures, such as the Housekeeping and Maintenance Department Responsibilities and Environmental Services Guidelines, were not effectively implemented, as evidenced by the lack of regular maintenance and cleaning. The Director of Environmental Services and the Corporate Quality Manager confirmed that rounds conducted in the facility did not adequately address environmental concerns, and there was no documentation of a plan to address the identified deficiencies. The Administrator, who had recently started working at the facility, was unaware of any formal plans to renovate or address the environmental issues.
Facility's QAPI Program Lacks Comprehensive Environmental Maintenance
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that ensured a clean, safe, and homelike environment for residents. The facility's QAPI plan was undated and lacked specific preventative maintenance measures for the upkeep of the resident environment, such as walls, carpets, and window treatments. The QAPI calendar for 2024 did not include the facility's physical environment as an agenda item, and the Director of Environmental Services was frequently absent from QAPI meetings, with no reports on the facility environment being documented. During environmental tours, surveyors observed significant deficiencies in the facility's physical environment. In the Meadows Rehabilitation Unit, the carpet was worn and stained, doors were scratched and discolored, and resident rooms had torn wallpaper and accumulated dirt. The [NAME] Unit had similar issues, with stained carpets, scratched doors, and poorly repaired walls. The Dementia Special Care Unit (DSCU) had lifted floor planks creating trip hazards, missing wall panels with sharp edges, and soiled, worn furniture. Interviews with the Director of Environmental Services and the Administrator revealed a lack of a maintenance system or plan to address wear and tear in resident areas. The Director admitted to having no documentation or timeline for renovation and repair needs, and the Administrator acknowledged that environmental concerns should have been addressed by the Quality Assurance Committee prior to the survey.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
