Charlwell House Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwood, Massachusetts.
- Location
- 305 Walpole Street, Norwood, Massachusetts 02062
- CMS Provider Number
- 225208
- Inspections on file
- 25
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Charlwell House Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents received pain medications outside of the prescribed pain scale parameters, with staff administering Oxycodone for pain levels not indicated in the physician's orders and failing to offer Tylenol as ordered. Nursing staff and the DON confirmed that medications were not administered according to professional standards or physician instructions.
A resident with a history of diabetes, sacral pressure ulcer, and lower extremity amputations was admitted with pressure ulcers on both heels. Facility staff failed to properly assess, document, and provide individualized treatment for these wounds, instead using generalized treatment orders and neglecting to update care based on hospital recommendations. The wounds were not reviewed by the wound physician, and staff focused on other wounds, resulting in incomplete documentation and inadequate care for the heel ulcers.
Surveyors found that medications requiring refrigeration, including various types of insulin and injection pens, were stored at improper temperatures in both medication rooms. Temperatures ranged from 30°F to 70°F, outside the required 36°F to 46°F range. Staff and the DON confirmed knowledge of proper storage requirements, but the temperature discrepancies were not addressed at the time of observation.
A facility failed to maintain accurate infection surveillance and proper wound care practices. Infection documentation was incomplete, with missing signs, symptoms, and culture results for several infections. In one case, a nurse did not follow hand hygiene or glove change protocols during a dressing change for a resident with pressure ulcers, and re-applied a contaminated dressing. These actions did not meet facility policy or infection control standards.
A resident with a history of diabetes and lower extremity amputations experienced a change in a right lower leg wound from superficial to 100% slough. Nursing staff did not document the change or notify the physician, and the physician was unaware of the wound's deterioration until it was observed during a survey. Facility policy requiring documentation and notification of wound changes was not followed.
Nursing staff did not provide a resident with a written summary of the baseline care plan within 48 hours of admission, as required. The resident, who had multiple chronic conditions, did not receive documentation of initial goals, medications, dietary instructions, or planned services and treatments. Interviews and record review confirmed the care plan summary was not developed or shared in the required timeframe.
A resident with quadriplegia and muscle weakness, who was cognitively intact and required assistance with activities of daily living, did not have a comprehensive care plan addressing their smoking status and preferences. Although facility policy required documentation of smoking-related needs and staff were aware of the resident's smoking habits and required assistance, no individualized smoking care plan was developed or implemented, as confirmed by nursing staff and the DON.
A resident who was dependent on staff for ADLs and cognitively intact was observed over several days to have long, dirty fingernails, despite facility policies requiring regular nail care. The resident reported not being offered nail care, and there was no documentation of refusal or provision of this care, indicating a failure by staff to follow care plans and facility procedures.
A resident with multiple lower extremity wounds did not consistently receive ordered wound care treatments, and staff failed to document wound assessments or changes in wound condition. Nursing records lacked evidence of daily dressing changes, and significant changes in the wound, such as the development of 100% slough, were not recorded or reported. The DON confirmed that wound care documentation and individualized treatment orders were not followed.
A resident with diabetes and bilateral lower extremity amputations did not receive proper diabetic foot care, including daily washing and moisturizing, as required by physician orders and hospital recommendations. Documentation showed missed care, and staff interviews revealed a lack of understanding of diabetic foot care standards. Additionally, a podiatry appointment ordered for the resident was not scheduled for over three weeks, with staff unaware of the order until the survey.
A pharmacist did not identify or report a medication irregularity during the monthly drug regimen review, resulting in a resident receiving 37 more doses of Flagyl than intended for treatment of a kidney infection and abscess. The facility's policy required thorough review and reporting of such discrepancies, but the error was not detected or communicated by the pharmacist or staff during the review process.
A resident with a history of kidney infection and abscess received 127 doses of Flagyl, exceeding the intended 90 doses, due to a transcription error in the physician’s order that included both a duration in days and a total number of doses. The error was not identified or corrected, and there was no documentation of provider consultation to extend the medication.
A resident with a lower extremity fracture did not receive physical and occupational therapy at the frequency ordered by the physician, with multiple weeks showing missed or reduced therapy sessions. The Director of Rehab confirmed the missed sessions and lack of required documentation for these absences.
The facility failed to maintain complete and accurate medical records for three residents, as CNA ADL Flow Sheets were often left blank. Despite the facility's policy requiring daily documentation, CNAs cited being too busy as a reason for incomplete records. The former DON acknowledged the issue, while the Interim DON was unaware of the extent of the problem.
The facility failed to follow professional standards for two residents, leading to significant deficiencies. One resident missed 65 doses of Plavix due to a failure in medication reconciliation, resulting in a DVT. Another resident's midline catheter dressing was not changed as per physician's order and facility policy.
A resident experienced a four-month delay in scheduling cataract surgery due to the facility's failure to reschedule a canceled appointment. The resident, who had impaired vision and was cognitively intact, expressed frustration over the delay, which prevented them from reading the Bible. The facility's consultant optometrist had to intervene to ensure the resident received the necessary care.
The facility failed to ensure medications were properly labeled with a shortened expiration date upon opening and the resident's name was on the medication in two of four medication carts. Multiple inhalers and nasal sprays lacked open dates or shortened expiration dates, and some medications lacked resident identifiers. Nurses and the DON confirmed these deficiencies.
The facility failed to ensure that residents were offered the pneumonia vaccine within 30 days of admission, as required by their policy. Interviews revealed a lack of a comprehensive vaccination roster and a shift in focus to COVID vaccinations, leading to the oversight.
The facility failed to implement an effective pest control program, resulting in multiple observations of mice and droppings in resident units, a closed unit, and the laundry room. Residents reported frequent sightings of mice, and the surveyor found significant evidence of mice droppings in various areas. Staff efforts to address the issue were insufficient, and proper sanitation and documentation practices were not maintained.
The facility failed to obtain a court-approved Treatment Plan for the administration of antipsychotic medication for a resident with dementia and paranoid personality disorder. The resident's legal guardian signed the consent form without the necessary court authorization, and the medication was administered as ordered by the physician.
A facility failed to ensure proper care of a resident's suprapubic catheter bag, which was observed in direct contact with the floor, contrary to facility policy. Both a nurse and the DON confirmed that the bag should be hung from the bed to avoid contamination.
A facility failed to replace a resident's oxygen tubing weekly as ordered by the physician. The resident, who required continuous oxygen due to chronic lung disease, had tubing that had not been changed for nearly a month. Staff confirmed the tubing should have been replaced weekly but was not.
Failure to Administer Pain Medication According to Physician Orders and Pain Scale
Penalty
Summary
The facility failed to ensure that pain medications were administered in accordance with professional standards of practice and physician orders for two residents. For one resident with osteoporosis and muscle weakness, the physician's order specified that Oxycodone 5 mg should be administered every eight hours as needed for pain rated 4-6 on the pain scale. However, medication administration records showed that Oxycodone was given multiple times for pain scores less than 4, and there was no nursing documentation explaining the rationale for administering the medication outside the prescribed parameters. The nurse confirmed that the medication was administered outside of the physician's order. For another resident with spinal stenosis and chronic obstructive pulmonary disease, the physician's orders specified Tylenol for pain rated 1-3 and Oxycodone for pain rated 3-6. The resident reported that staff did not ask about pain levels and provided Oxycodone upon request, without offering Tylenol. Medication administration records indicated that Oxycodone was administered outside the ordered pain scale parameters on several occasions, including for pain ratings of 0, 2, 7, 8, and 10, while Tylenol was not administered at all. The nurse acknowledged that the medications were not given according to the physician's orders and that Tylenol should have been administered for lower pain scores. Interviews with nursing staff and the Director of Nursing confirmed that as-needed pain medications are typically tied to specific pain scale ratings and should be administered according to physician orders. The Director of Nursing stated that pain medication should only be given within the prescribed pain scale rating attached to the order. The facility's failure to follow these standards resulted in the administration of pain medications outside of the prescribed parameters for both residents.
Failure to Assess and Treat Bilateral Heel Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate assessment, documentation, and treatment for pressure ulcers on the bilateral heels of a resident with a complex medical history, including diabetes, a stage 4 sacral pressure ulcer, and previous lower extremity amputations. Upon admission and subsequent readmissions, the resident was noted to have pressure ulcers on both heels, but the facility's documentation lacked essential details such as wound stage, measurements, descriptions, and specific treatments. The care plans and treatment administration records grouped multiple wounds together under generalized treatment orders, rather than specifying individualized care for each wound as required by facility policy and professional standards. Despite hospital discharge summaries providing clear instructions for wound care, including the use of specific dressings and follow-up with a podiatrist, the facility did not update treatment orders to reflect these recommendations. There was no evidence that the wounds on the heels were properly assessed or that the recommended treatments were implemented. The wound physician consultant did not review the heel ulcers, and the nursing staff focused primarily on the sacral wound, neglecting the bilateral heel ulcers. Interviews with staff revealed a lack of awareness and oversight regarding the presence and severity of the heel wounds, and the documentation remained incomplete or inaccurate throughout the resident's stay. Direct observation by the surveyor, DON, and wound nurse confirmed the presence of significant pressure ulcers on both heels, with one being unstageable due to necrotic tissue and the other a stage 3 ulcer with slough. Staff interviews further indicated that wound assessments and documentation were not consistently performed, and treatment orders were not individualized or updated as needed. The facility's failure to assess, document, and treat the resident's heel pressure ulcers in accordance with professional standards resulted in a deficiency in pressure ulcer care.
Improper Storage Temperatures for Refrigerated Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration were not stored at the proper temperatures in both medication rooms. In Unit A, the refrigerator temperature was found to be 70°F, and in Side B, it was 59°F during initial checks. Both refrigerators contained various medications, including multiple types of insulin, Mounjaro injection pens, and suppositories, all of which require storage between 36°F and 46°F as per the facility's policy and professional standards. Staff interviews confirmed awareness of the required temperature range, and logs indicated that out-of-range temperatures should be documented and reported immediately. On a subsequent day, the refrigerator on Side B was found to be at 30°F and later at 31°F, again outside the acceptable range. The same types of medications were observed stored in these conditions. The DON stated she was unaware that both refrigerators were out of range and acknowledged that medications should be stored at the proper temperature. No evidence was provided that the temperature discrepancies were addressed at the time of the survey, and the improper storage persisted across multiple observations.
Deficient Infection Surveillance and Improper Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance and improper wound care practices. Review of the facility's infection surveillance policy and line listings for several months revealed that documentation of signs and symptoms of illness was frequently missing, and culture results identifying organisms for urinary tract infections were often not included. Additionally, a significant laboratory finding of ESBL in a resident's urine culture was not recorded on the facility's infection line listing. Interviews with the Infection Control Nurse and Regional Nurse confirmed that culture results, lab reviews, and symptoms were not consistently documented on the infection tracker or line listing, contrary to facility policy and infection surveillance standards. A specific incident involving a resident with dementia and unstageable pressure ulcers highlighted further deficiencies in infection control practices. During a wound dressing change, a nurse failed to perform hand hygiene or change gloves between removing old dressings and cleansing wounds on both feet. The nurse also re-applied a dressing that had fallen onto a towel and bed linens, rather than using a new, clean dressing. These actions were observed directly by a surveyor and later acknowledged by the nurse and the Director of Nursing as not meeting the facility's wound care protocol, which requires hand hygiene and glove changes after removing old dressings and prohibits re-applying contaminated dressings. The combination of incomplete infection surveillance documentation and improper wound care procedures demonstrates the facility's failure to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. These deficiencies were confirmed through record review, staff interviews, and direct observation.
Failure to Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's wound status. A resident with a history of diabetes, multiple lower extremity amputations, and chronic wounds was admitted with several wounds, including a superficial wound on the right lower leg. Hospital discharge paperwork indicated a wet to dry dressing was ordered for bilateral shin wounds, but the facility's documentation and treatment orders did not reflect this change. Upon observation, the wound on the right lower leg had progressed from a superficial wound to one with 100% slough, but this change was not documented or communicated to the physician. Nursing staff providing care to the resident did not document the presence of slough or notify the physician of the wound's deterioration. The physician confirmed she was not made aware of the change until the wound was observed by the surveyor and facility staff. The facility's own wound care policy required documentation of wound assessment data and notification of changes, but these procedures were not followed, resulting in a failure to inform the physician of the resident's wound progression.
Failure to Provide Baseline Care Plan Summary Within 48 Hours of Admission
Penalty
Summary
Nursing staff failed to provide a resident and/or their representative with a written summary of the baseline care plan within 48 hours of admission. The resident, who was admitted with interstitial pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and neurocognitive disorder with Lewy Bodies, did not receive documentation outlining initial goals, current medications, dietary instructions, or the services and treatments to be administered. Medical record review confirmed the absence of this summary, and interviews with the resident, a nurse, and the administrator verified that the baseline care plan was not developed or shared within the required timeframe.
Failure to Develop and Implement Individualized Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan addressing the smoking status and preferences of one resident. Despite facility policies requiring the establishment of safe smoking practices and the inclusion of smoking-related privileges, restrictions, and concerns in the care plan, there was no evidence that such a care plan was created for this resident. The resident, who was admitted with quadriplegia and muscle weakness and was cognitively intact, required assistance with activities of daily living and used tobacco. Nursing assessments indicated the need for a smoking apron, one-to-one assistance when smoking, and supervision by staff or family when using nicotine-related devices. However, a review of the resident's comprehensive care plans revealed no documentation of a smoking care plan. Interviews with nursing staff and the DON confirmed that the resident's smoking needs and preferences were not reflected in the care plan, despite staff awareness of the resident's smoking status and required assistance. The facility's failure to document and individualize a care plan for the resident's smoking needs constituted a deficiency in meeting regulatory requirements.
Failure to Provide Nail Care as Part of ADL Support
Penalty
Summary
The facility failed to provide adequate activity of daily living (ADL) care related to personal grooming for one resident who was dependent on staff for ADLs and mobility. The resident, who was cognitively intact and had diagnoses including osteoarthritis and depression, was observed on multiple occasions to have long, jagged fingernails with a brown/red substance present on and under the nails. The resident reported that staff did not offer nail care and expressed a preference for shorter nails. There was no documentation indicating that the resident refused nail care, and the care plan and CNA Kardex both specified that nail care should be performed on bath days and as needed, with any refusals or changes to be reported to nursing staff. Interviews with staff revealed that nail care was expected to be performed on bath days or sooner if needed, and that refusals should be documented and reported. However, the nurse interviewed was unsure where refusals would be documented, and the DON confirmed that nail care should be part of daily ADL care and refusals should be reported and documented. Despite these policies and expectations, the resident's nails remained untrimmed and uncleaned over several days, and there was no evidence in the medical record of nail care being provided or refused.
Failure to Provide and Document Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care treatment and assessment in accordance with professional standards for a resident with multiple lower extremity wounds. Despite having clear orders for daily wound care, including normal saline cleansing and bacitracin with Mepore dressing, documentation showed that treatments were not administered on several specified days. There was no evidence in the medical record or nursing progress notes that the resident refused care on those days, nor was there documentation explaining the missed treatments. Additionally, the facility did not properly assess or document the condition of the resident's right lower leg wound. Nursing assessments and progress notes lacked detailed descriptions, measurements, or updates on the wound's status, making it impossible to monitor for changes. When the wound changed from a superficial state to one with 100% slough, this significant alteration was neither documented nor reported by the nurse providing care. The wound order also failed to specify treatments for each individual wound, instead clustering multiple wounds under a single order, contrary to facility policy. Interviews with the resident and staff confirmed that daily dressing changes were not consistently provided, and that wound assessments were incomplete. The DON acknowledged that wound descriptions and drainage should have been documented and that each wound should have had a separate treatment order. The lack of proper documentation and assessment led to an inability to track the wound's progression and ensure appropriate care was delivered.
Failure to Provide Diabetic Foot Care and Schedule Podiatry Appointment
Penalty
Summary
The facility failed to provide appropriate foot care for one resident with a history of diabetes and bilateral lower extremity amputations. Despite physician orders and hospital recommendations for diabetic foot care, including daily washing, moisturizing, and inspection of the feet, the facility did not ensure these interventions were consistently performed. Documentation in the Treatment Administration Record and nursing progress notes showed multiple missed entries for diabetic foot care, and interviews with nursing staff revealed a misunderstanding of the required care, with some staff only inspecting the feet and not washing or applying lotion as needed. Observation of the resident confirmed dry, flaky skin and removal of skin with dressing changes, indicating inadequate foot care. Additionally, the facility failed to schedule a podiatry appointment as ordered by the physician and recommended by the hospital following the resident's discharge. Despite a specific order entered by the DON for a podiatry consult, there was no evidence that an appointment had been scheduled more than three weeks after the order was placed. Interviews with facility staff confirmed that the receptionist was not aware of the need to schedule the appointment until the day of the survey, further demonstrating a lapse in following through with necessary medical care for the resident.
Pharmacist Failed to Identify Excessive Antibiotic Dosing During Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review (MRR) conducted by the consultant pharmacist identified and reported medication irregularities for one resident. Specifically, the pharmacist did not detect or report that the resident received an excessive number of doses of the antibiotic Flagyl, exceeding the intended duration as specified in the hospital discharge summary and physician's orders. The resident, who had a history of pyelonephritis and renal and perinephric abscess, was prescribed Flagyl for a specific number of doses, but the medication administration record showed that the resident received 127 doses instead of the intended 90. The facility's policy required the pharmacist to thoroughly review medical records to identify and report medication irregularities, such as medications ordered in excessive doses or without clinical indication. Despite this, the pharmacist did not identify the discrepancy between the number of days and doses in the order, nor did she report it as an irregularity. Interviews with facility staff, including the consultant pharmacist, regional nurse, and DON, confirmed that the MRR process should have detected and reported this issue, but it was missed during the monthly reviews.
Excessive Administration of Antibiotic Due to Order Transcription Error
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the administration of the antibiotic Flagyl. The resident, who had a history of pyelonephritis and renal and perinephric abscess, was admitted with a hospital discharge summary indicating a prescription for Flagyl to be given three times daily for a total of 90 doses. However, the physician’s order was transcribed to include both a duration of 89 days and 90 doses, leading to confusion. As a result, the resident received 127 doses of Flagyl, exceeding the intended 90 doses by 37. Review of the medication administration records confirmed the excessive administration, and there was no documentation in the progress notes that a provider had been consulted to extend the duration of the medication. Interviews with facility staff, including the physician, regional nurse, and DON, revealed that the error stemmed from the conflicting information in the order regarding both days and doses, and no one recalled authorizing the extended duration.
Failure to Provide Ordered Physical and Occupational Therapy
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as ordered for one resident with a right lower extremity tibia fracture status post-surgical repair. Physician's orders required PT five times per week for multiple consecutive weeks and OT five times per week for several weeks. However, record review showed that for eight out of fourteen weeks, the resident did not receive PT at the ordered frequency, with some weeks having as few as two or three visits. Similarly, for three out of six weeks, the resident did not receive OT at the ordered frequency, with one week having only one visit and another week with no visits at all. Interviews with the resident's representative and the Director of Rehab confirmed that the resident did not receive the prescribed therapy sessions. The Director of Rehab acknowledged that therapy should have been provided according to physician's orders and that documentation, such as encounter notes or missed visit notes, was lacking for the missed sessions. There was no additional evidence in the medical record to account for the missed therapy visits.
Incomplete CNA Documentation in Resident ADL Flow Sheets
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three sampled residents, as required by their policy on charting and documentation. The deficiency was identified through a review of the Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets, which were found to be inconsistently completed, with many entries left blank. For Resident #1, significant gaps in documentation were noted across multiple shifts over several months, despite the resident's complex medical conditions, including Alzheimer's and dysphagia. Similarly, Resident #2 and Resident #3 also had incomplete ADL Flow Sheets, with numerous days and shifts lacking documentation of care provided. Interviews with CNAs and nursing leadership revealed that the CNAs were aware of the requirement to document care daily but cited being too busy as a reason for not completing the documentation. The former Director of Nursing acknowledged the ongoing issue with CNA documentation, while the Interim Director of Nursing was unaware of the extent of the problem. The facility's policy mandates that all care and services provided to residents be documented accurately and completely, yet this was not adhered to, leading to the identified deficiency.
Failure to Follow Professional Standards for Medication Reconciliation and Dressing Changes
Penalty
Summary
The facility failed to follow professional standards for two residents, leading to significant deficiencies. For Resident #24, the facility did not reconcile the resident's medications from the hospital discharge summary, resulting in the resident missing 65 doses of Plavix, an antiplatelet medication, from 10/18/23 to 12/18/23. This oversight occurred despite clear discharge instructions to restart the medication seven days post-surgery. The resident, who had a history of stroke and heart surgery, subsequently developed a deep vein thrombosis (DVT) in the right leg, which was confirmed by a Doppler ultrasound on 12/12/23. Interviews with the resident, physicians, and the Director of Nurses (DON) revealed that the medication reconciliation process was not followed, and the resident did not see a cardiologist post-surgery as recommended. For Resident #219, the facility failed to change the transparent semi-permeable membrane (TSM) dressing on the resident's left upper extremity midline catheter in accordance with the physician's order and facility policy. The resident was readmitted to the facility on 4/2/24 with a midline catheter placed at the hospital on 3/31/24 for intravenous antibiotics. Observations on 4/9/24 and 4/10/24 showed that the TSM dressing was clean and intact but not dated. Review of the Treatment Administration Record (TAR) indicated that the dressing change order was not documented as completed. The DON confirmed that the facility's policy to change midline catheter dressings upon readmission and every seven days thereafter was not followed. These deficiencies highlight significant lapses in the facility's adherence to professional standards and policies, particularly in medication reconciliation and catheter dressing changes. The failure to restart Plavix for Resident #24 and the omission of the dressing change for Resident #219 indicate a need for improved processes and oversight to ensure resident safety and compliance with medical orders.
Delay in Scheduling Cataract Surgery for Resident
Penalty
Summary
The facility failed to obtain timely eye care services for a resident with age-related nuclear cataract in the right eye, resulting in a four-month delay in scheduling follow-up appointments for cataract surgery. The resident, who was cognitively intact and had impaired vision, was initially seen by an eye doctor who recommended cataract surgery. However, the initial appointment was canceled due to lack of transportation, and the follow-up appointments were not rescheduled promptly, causing a significant delay in the resident's care. The resident expressed frustration during interviews, stating that the delay in cataract surgery prevented them from reading the Bible and scriptures, which was important for their well-being. The facility's consultant optometrist confirmed that the resident's cataract surgery was recommended in May and August of the previous year, but the necessary follow-up was not conducted. The optometrist had to personally intervene in December to ensure the resident received an appointment at the VA. Interviews with facility staff, including the Assistant Director of Nurses and the Social Worker, revealed that the delay was acknowledged, and efforts were made to rectify the situation. The resident was eventually scheduled for cataract surgeries in April and May of the following year. The Director of Nurses admitted that the scheduling took longer than it should have, highlighting a lapse in the facility's process for managing follow-up appointments for essential medical services.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with current accepted professional standards. Specifically, medications were not properly labeled with a shortened expiration date upon opening, and the resident's name was missing on the medication in two of four medication carts. Observations included multiple inhalers and nasal sprays without open dates or shortened expiration dates, and some medications lacked resident identifiers. Nurse #2 and Nurse #3 confirmed that these medications should have been dated upon opening and labeled with the resident's name, but they were not. During interviews, both nurses acknowledged the labeling deficiencies, and the Director of Nursing (DON) confirmed that medications with a shortened expiration date must be labeled with the open date upon opening and must be discarded if not labeled. The DON also stated that medications such as inhalers and eye drops should be used for only one resident and must be clearly labeled with the resident's name to prevent administration errors. The failure to adhere to these standards was observed in multiple instances, indicating a systemic issue in medication management within the facility.
Failure to Offer Pneumonia Vaccinations to Residents
Penalty
Summary
The facility failed to ensure that five sampled residents were offered the pneumonia vaccine within 30 days of admission, as required by their policy. The residents in question were admitted between February 2017 and February 2024, and none had records indicating they were offered or received the pneumonia vaccine. The facility's policy, revised in March 2023, mandates that residents be assessed for eligibility and offered the vaccine unless medically contraindicated or already vaccinated. However, this policy was not followed for the sampled residents. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that there was no comprehensive roster of residents who had received, refused, or required the pneumonia vaccine. The IP admitted to shifting focus to COVID vaccinations in November 2023, which led to the oversight of pneumococcal vaccinations. The DON confirmed that the facility's policy was to offer the vaccine within 30 days of admission, but this was not consistently implemented, resulting in the deficiency.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by multiple observations of mice and mice droppings in various areas, including resident units, a closed unit, and the laundry room. The Director of Nurses confirmed the absence of a pest control policy. Pest sighting logs were outdated, with the last entries dating back several months, indicating a lack of consistent monitoring and documentation of pest activity. Residents reported frequent sightings of mice in their rooms, particularly at night. The surveyor observed mice droppings in several resident rooms, including behind furniture, in closets, and on shelves. Personal items of residents and staff were found contaminated with mice droppings, and some residents reported seeing mice running around daily. The surveyor also found significant evidence of mice droppings in common areas such as the small dining room, tub rooms, and the laundry room. Interviews with staff revealed that while some efforts were made to address the pest issue, such as plugging holes and placing sticky traps, these measures were insufficient. The Housekeeping Manager acknowledged the mice problem and described the cleaning routines, but admitted that closets were not cleaned due to residents' personal items. The Contracted Pest Control Manager confirmed that the facility staff were educated on proper pest control measures, but the facility failed to maintain adequate sanitation and documentation practices, contributing to the ongoing pest issue.
Failure to Obtain Court-Approved Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain a court-approved Treatment Plan for the administration of antipsychotic medication for a resident diagnosed with dementia with agitation and paranoid personality disorder. The resident was admitted to the facility with a legal guardian appointed by the Commonwealth of Massachusetts Probate and Family Court, who only had the authority to admit the resident to the nursing facility. The clinical record did not include a court authorization for a Treatment Plan for the administration of antipsychotic medication, yet the resident was administered Quetiapine Fumarate as per the physician's orders starting from the admission date. The Informed Consent for Psychotropic Administration Form was signed by the legal guardian, who attested to having substituted judgment authority and claimed that the [NAME] Monitor had been informed and authorized the medication. However, the Director of Social Services confirmed that the guardian could not consent to the administration of antipsychotic medication without a court-approved Treatment Plan. Despite this, the medication was administered as ordered, and the legal process for obtaining the Treatment Plan had been initiated but was not yet in place.
Improper Positioning of Suprapubic Catheter Bag
Penalty
Summary
The facility failed to ensure proper care and treatment of a resident's urinary drainage device, specifically a suprapubic catheter bag. The resident, who was admitted with diagnoses including paraplegia and urine retention, was observed with the drainage bag's port in direct contact with the floor. This observation was made despite the facility's policy, which mandates that catheter tubing and drainage bags be kept off the floor to prevent contamination. The resident's physician had ordered regular monitoring and maintenance of the suprapubic catheter, including weekly changes of the drainage bag and tubing, but these orders were not followed correctly. During an interview, a nurse confirmed that the drainage bag should not touch the floor and should be hung from the bed to avoid infection control issues. The Director of Nursing also stated that continuous drainage bags must always be positioned off the floor to prevent contamination. The failure to adhere to these guidelines resulted in a deficiency in the care provided to the resident, as the improper positioning of the drainage bag posed a risk of contamination and infection.
Failure to Replace Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen delivery equipment for Resident #40 was replaced in accordance with the physician's order. Resident #40, who was admitted in March 2023 with chronic lung disease, required continuous oxygen at 2 liters per minute via an oxygen concentrator through a nasal cannula. The physician's order specified that the oxygen tubing be changed every night shift on Sunday. However, during an observation on 4/9/24, it was noted that the nasal cannula oxygen tubing had not been changed since 3/13/24, as indicated by a piece of white tape affixed to the tubing. The resident was unaware of the last change date. Nurse #4 confirmed that the tubing should have been replaced weekly on Sunday during the 11:00 P.M.-7:00 A.M. shift but was not.
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.
