Chestnut Hill Health And Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Longmeadow, Massachusetts.
- Location
- 32 Chestnut Street, East Longmeadow, Massachusetts 01028
- CMS Provider Number
- 225303
- Inspections on file
- 21
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Chestnut Hill Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
A newly admitted resident with multiple chronic and acute conditions did not receive several ordered medications due to unavailability, as nursing staff did not request STAT pharmacy delivery or notify the provider for alternative orders, contrary to facility policy. Documentation and interviews confirmed that required steps to obtain and administer the medications in a timely manner were not followed.
Staff in the kitchen did not consistently wear hair restraints while preparing and cooking food, and failed to monitor and document the final internal temperatures of several hot food items before serving them to residents. Some food items were held and served at temperatures below required standards, and residents reported receiving cold food. The Food Service Director confirmed that these practices did not comply with facility policy or food safety standards.
Staff failed to consistently use appropriate PPE, clean and disinfect surfaces and equipment, and follow contact and enhanced barrier precautions for multiple residents with infections or wounds. These lapses included not wearing gowns and gloves when required, improper cleaning of overbed tables after removal of used urinals, and using shared medical equipment without effective disinfection between residents, as confirmed by staff and management interviews.
A resident with dementia experienced a significant decline in ADLs, becoming dependent on staff for multiple tasks after a fall and discontinuation of therapy. Despite facility policy requiring a Significant Change in Status Assessment (SCSA) for such declines, the assessment was not completed, as confirmed by staff review of the resident's medical record.
A resident with Multiple Sclerosis was admitted without any documented mental illness, but later received several new mental health diagnoses, including adjustment disorder and delusional disorder. Despite these new diagnoses, the facility did not conduct or document a required PASRR Level II Evaluation or referral, as confirmed by staff interviews.
A resident with a history of depression, prescribed antidepressant medications, and who had consented to behavioral health services, did not receive those services as required. Despite documented requests and care plan interventions, the facility failed to ensure the referral process was completed and did not provide the necessary behavioral health support.
Two residents were administered incorrect medications during a medication pass, resulting in a medication error rate of 7.6%, which exceeds the acceptable threshold. An LPN gave one resident a different calcium supplement than ordered and another resident a different laxative than prescribed, documenting both as if the correct medications had been given. The DON confirmed that only prescribed medications should have been administered.
Breakfast items, including pureed scrambled eggs, oatmeal, pancakes, and French toast casserole, were served at temperatures well below the required 135°F, with several staff and residents noting the food was cool or cold. The pureed eggs also had an inappropriate gritty texture due to the addition of thickener, which staff acknowledged was not suitable for eggs.
The facility inaccurately coded MDS assessments for two residents, including one instance where a resident was marked as having a fall with major injury despite no evidence or report of such an event, and another where a resident's discharge destination was incorrectly recorded as a hospital instead of home. These errors resulted in assessments that did not accurately reflect the residents' conditions or discharge locations.
A resident at risk for pressure injuries did not have complete CNA documentation for October 2024, with numerous blank spaces in the Turning and Repositioning, Bed Mobility, Preventative Skin Care, and Skin Observation tasks. Interviews with staff confirmed that documentation was expected to be completed by the end of each shift, but this was not done, leading to an incomplete medical record.
Failure to Provide Timely Medication Administration for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a newly admitted resident received medications as ordered by their provider. The resident, who had diagnoses including hypertension, COPD, and a urinary tract infection, had physician orders for several medications to treat both chronic and acute conditions. Despite these orders, the resident did not receive multiple scheduled doses of Spiriva, Symbicort, Diltiazem, and Cefpodoxime as documented in the Medication Administration Record (MAR) and corresponding nursing notes, which indicated the medications were not available and were pending arrival from the pharmacy. Facility policies required that when medications were not available, nursing staff should contact the prescriber for directions and request STAT delivery from the pharmacy if needed. The pharmacy confirmed that the medication orders were received after regular hours and that a STAT order could have resulted in delivery within four hours, but no such request was made by the nursing staff. Nurses reported not administering the medications because they were not available in the facility’s medication storage and did not contact the pharmacy for STAT delivery, expecting the medications to arrive with the next scheduled delivery instead. Interviews with facility staff, including nurses, the unit manager, and the director of nursing, confirmed that the process for obtaining new admission medications was not followed as per policy. The staff did not contact the pharmacy for STAT delivery or notify the provider to discuss alternative medications when the ordered medications were unavailable. There was no documentation to show that the provider was contacted regarding the unavailability of the medications or to consider alternative treatments.
Failure to Use Hair Restraints and Monitor Food Temperatures in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, specifically regarding the use of hair restraints and the monitoring of food temperatures. Observations revealed that a cook was preparing and cooking food on the grill without wearing any type of hair restraint, in violation of the facility's policy which requires all kitchen staff to keep hair effectively restrained to prevent contamination. The cook admitted to sometimes not wearing a hair restraint and stated that no one had addressed this issue with him. The Food Service Director (FSD) confirmed that all staff were required to wear hair restraints in the kitchen. Additionally, the facility did not consistently monitor or document the final internal temperatures of cooked foods prior to serving them to residents. During breakfast service, it was observed that certain food items, such as pureed eggs and minced and moist pancakes, were held at temperatures below the required standard, with recorded temperatures of 80°F and 100°F, respectively. The cook acknowledged that these were typical holding temperatures and admitted to not checking the final cooked temperatures for these or for special order items like sausage patties. The FSD stated that all hot foods should be held at 135°F and that temperatures must be monitored before serving, but the Food Temperature Log did not reflect proper monitoring for all items. Resident feedback during a council meeting indicated that some breakfast items, including eggs, were served cold. The FSD later confirmed that several residents had been served the under-temperature food items and that the temperature log was updated only after reheating, without documentation of the initial final cooked temperatures. The lack of proper temperature monitoring and failure to use hair restraints represent noncompliance with both facility policy and food safety standards.
Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for four residents, resulting in multiple deficiencies related to the use of personal protective equipment (PPE), cleaning and disinfection of surfaces and equipment, and implementation of contact and enhanced barrier precautions. For one resident with a diagnosis of Clostridium Difficile (C-Diff), staff entered the room and handled items such as the breakfast tray and call bell without donning gloves or gowns, despite clear signage and physician orders for contact precautions. The Director of Nursing confirmed that staff should have worn appropriate PPE in these situations due to the highly contagious nature of C-Diff. In another instance, a resident's overbed table was not properly cleaned and disinfected after a used urinal was removed and before a meal tray was placed on it. The staff member used only a dry paper towel rather than a disinfectant wipe, and both the CNA and DON acknowledged that proper disinfection was not performed, which was inconsistent with facility policy and infection control standards. Additionally, shared medical equipment, specifically a portable pulse oximeter, was used on a resident with C-Diff and then on another resident after being wiped with a product not effective against C-Diff spores. The unit manager confirmed that dedicated equipment should have been used and that the cleaning product available was not appropriate for C-Diff. For a resident on Enhanced Barrier Precautions due to pressure ulcers and other conditions, staff failed to wear gowns while providing high-contact care such as feeding, repositioning, and handling bed linens, despite signage and care plan interventions requiring both gowns and gloves. Multiple staff members and the unit manager acknowledged that gowns should have been worn during these activities. These failures were observed directly by surveyors and confirmed in interviews with staff and management, demonstrating lapses in adherence to established infection control policies.
Failure to Complete Significant Change in Status Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a notable decline in activities of daily living (ADLs). According to the facility's policy, an SCSA must be conducted when the interdisciplinary team (IDT) determines that a resident has undergone a significant change, defined as a major decline or improvement affecting more than one area of health status and requiring care plan review. The resident in question, admitted with dementia, initially required partial assistance with some ADLs and supervision for others. Subsequent assessments showed a marked decline, with the resident becoming dependent on staff for multiple ADLs, including upper body dressing, rolling, transferring, and wheelchair mobility. Despite this decline, the medical record did not show that an SCSA was completed after the change in the resident's condition. During an interview, consulting staff acknowledged that after a fall with injury, the IDT believed the decline would be self-limiting. However, by the time of a later assessment, the resident had not improved and was no longer receiving therapy, with continued decline in more than two ADL areas. Staff confirmed that an SCSA should have been completed at that time, but it was not.
Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation after the identification of new mental health diagnoses. The resident was originally admitted with a diagnosis of Multiple Sclerosis and, at the time of admission, had no documented mental illness or disorder, resulting in a negative PASRR screening. However, subsequent diagnoses were made, including Adjustment Disorder, Depression, Anxiety Disorder, and Delusional Disorder, with the first new diagnosis appearing in May 2023 and the most recent in December 2024. Despite these new mental health diagnoses, there was no documented evidence in the resident's medical record that a PASRR Level II Evaluation was conducted or that a referral was made to the PASRR office as required. During an interview, the facility's social worker confirmed that a new PASRR should be completed and submitted whenever a new mental health diagnosis is identified, but the facility was unable to provide evidence that this process occurred for the resident in question.
Failure to Provide Timely Behavioral Health Services for Resident on Antidepressants
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who had a diagnosis of depression and was prescribed antidepressant medications. The resident had consented to receive behavioral health services, as documented in the clinical record and care plan, and had expressed a willingness to speak with a therapist or counselor about increased feelings of sadness and loss of independence. Despite a request for behavioral health services being made and consent obtained, there was no evidence in the clinical record that the resident received any behavioral health services during their stay. Interviews with the resident confirmed ongoing symptoms of depression and a desire for additional support, while interviews with facility staff revealed that the process for referring the resident to behavioral health services was not completed as required. The consent form for behavioral health services was not properly sent to the psychiatric consultant, and there was a lack of follow-up to ensure the resident was seen. The facility's own audit later identified that the resident had not received the requested behavioral health services, but no evidence was found that services were provided prior to this discovery.
Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate below five percent, as required, resulting in a 7.6% error rate during the survey. Specifically, two residents received incorrect medications during observed medication administration passes. One resident, with a history of Multiple Sclerosis and osteoporosis, was ordered to receive Calcium 1200 mg daily but was instead given Calcium + Vitamin D 600 mg/10 mcg, as this was the medication available in the cart. The nurse documented administration of the ordered medication despite giving a different product. Another resident, with diagnoses including metabolic encephalopathy and a colostomy, was ordered Senna-S (Sennosides-Docusate Sodium) 8.6 mg/50 mg for constipation but was administered Senokot 8.6 mg instead. The nurse again documented administration of the ordered medication, though the correct product was not given, citing unavailability of the prescribed medication. The Director of Nursing confirmed that only the medications prescribed by the provider should have been administered and that the nurse should have obtained the correct medications if unavailable.
Deficient Food Temperature and Texture During Breakfast Service
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for one of its units, as required by its Meal Presentation/Refusal Policy. During a Resident Council meeting, three out of seven residents reported that breakfast items intended to be hot were served cold, with one specifically mentioning cold eggs. A test tray conducted by a surveyor, with participation from the unit manager, a nurse, and the MDS nurse, revealed that several breakfast items, including pureed scrambled eggs, oatmeal, pureed pancakes, and French toast casserole, were served at temperatures significantly below the required 135 degrees Fahrenheit for hot foods. The eggs were also noted to have a gritty texture, and both the eggs and oatmeal were described as cool or cold to taste. Interviews with staff confirmed these findings, with the unit manager and nurse both stating that the eggs were cool, and the MDS nurse indicating that the eggs and oatmeal would need to be reheated. The Food Service Director acknowledged that all hot foods should have been served at 135 degrees Fahrenheit and that the pureed eggs should not have had a gritty texture. It was further revealed that the cook had added thickener to the eggs due to their thin consistency, which the Food Service Director explained was inappropriate for eggs as it alters their texture.
Inaccurate MDS Coding for Falls and Discharge Destinations
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents out of a sample of 24. For one resident with a diagnosis of Diabetes Mellitus, the MDS assessment was coded to indicate that the resident had experienced a fall with major injury since the prior assessment. However, both the resident and consulting staff confirmed through interviews that no such fall or injury had occurred, and a review of the clinical record did not show evidence of any fall with major injury during the relevant period. For another resident admitted with Atrial Flutter, the MDS assessment was inaccurately coded to reflect a discharge to a short-term general hospital. In contrast, the clinical nurse progress note documented that the resident was actually discharged home with medications and services. The MDS nurse confirmed in an interview that the discharge destination had been coded incorrectly on the MDS assessment. These inaccuracies resulted in assessments that did not accurately reflect the residents' actual health status and discharge locations.
Incomplete CNA Documentation for Resident Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was at risk for pressure injuries and required assistance with bed mobility and Activities of Daily Living (ADLs). The Certified Nurse Aide (CNA) documentation for October 2024 was found to be incomplete, with numerous blank spaces in the Turning and Repositioning (T&R) Flowsheet, ADL Flowsheet for Bed Mobility, Preventative Skin Care, and Skin Observation tasks. These omissions occurred across various shifts, indicating a lack of proper documentation of the care provided to the resident. Interviews with CNAs, nurses, the Unit Manager, and the Director of Nursing (DON) confirmed that the documentation was expected to be completed by the end of each shift. The incomplete documentation gave the appearance that the resident did not receive the required care, as evidenced by the blank spaces in the records. The facility's policy on Charting and Documentation, revised in July 2017, required that all services provided to residents and any changes in their condition be documented, which was not adhered to in this case.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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