Chicopee Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicopee, Massachusetts.
- Location
- 44 New Lombard Road, Chicopee, Massachusetts 01020
- CMS Provider Number
- 225539
- Inspections on file
- 24
- Latest survey
- February 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Chicopee Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to notify the Physician or PA of significant weight loss in two residents, leading to a deficiency. One resident experienced severe weight loss due to conditions like diabetes and lung cancer, while another had a 25% weight loss in less than a month. Despite facility policies requiring notification of significant changes, there was no documentation or communication with the Physician or PA, as confirmed by interviews with staff.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a decline in ADLs and developed a new pressure ulcer. Initially, the resident required supervision and partial assistance for daily activities and had no pressure ulcers. Later, the resident required substantial assistance, was dependent for dressing, and developed an unstageable pressure ulcer. Despite these changes, no SCSA was completed, as confirmed by the MDS Nurse.
A resident with Type 2 Diabetes did not receive insulin within the prescribed time frame at a facility. Lantus SoloStar and Humalog KwikPen insulin were administered outside the one-hour window before or after the ordered times on multiple occasions. Interviews with nursing staff revealed awareness of the timing requirement, but there was a lack of proper documentation and communication when deviations occurred.
A resident with multiple health conditions experienced significant weight loss, which the facility failed to address adequately. Despite being prescribed a nutritional supplement, the resident frequently refused it, and it was discontinued without alternative interventions. Staff interviews revealed a lack of communication and documentation regarding the resident's nutritional needs and weight loss.
A facility failed to ensure that a Physician reviewed recommendations made by a Consultant Pharmacist during a monthly Medication Regimen Review for a resident with Vascular Dementia. The medical record lacked evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports, and the Director of Nursing could not provide additional information during the survey.
A facility failed to coordinate hospice care for a resident with a cerebral infarction by not designating an IDT member to work with hospice representatives and not maintaining the hospice plan of care. Interviews revealed that staff were unsure who was responsible for hospice documentation, leading to incomplete records.
The facility failed to implement proper infection control practices, including Enhanced Barrier Precautions, Contact Precautions, and Transmission-Based Precautions, for residents with wounds, C-Diff, and potential infections. Staff were observed not using required PPE, such as gowns and eye protection, and did not follow hand hygiene protocols, leading to potential contamination and spread of infections.
A resident with moderate cognitive impairment and dependency for transfers was found in a wheelchair missing a left armrest, exposing a metal bar and screw. This deficiency was not reported to maintenance as required by facility policy, posing a risk of injury. The Maintenance Director confirmed no prior work order was received.
A resident with multiple health conditions experienced a significant weight loss of 16.20% over six months, but the MDS assessment inaccurately indicated no significant weight loss. The MDS Nurse acknowledged the error, noting that the Dietician is responsible for section K of the MDS, and sometimes staff do not fully sign off on sections, leading to inaccuracies.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or Physician Assistant (PA) of significant changes in the condition of two residents, leading to a deficiency. For Resident #35, the facility did not inform the Physician or PA about the resident's severe weight loss, which was greater than 10% over six months. Despite the resident's diagnoses, including diabetes, lung cancer, and chronic kidney disease, and the refusal of nutritional supplements, there was no documented evidence that the provider was notified of the significant weight loss on specific dates. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the expected protocol of notifying the provider was not followed. Similarly, for Resident #58, the facility did not ensure that the Physician or PA was informed of a significant weight change and continued weight decline. The resident, who was admitted with conditions such as malnutrition and stage 4 pressure wounds, experienced a 25% weight loss in less than a month. Despite the dietician's recommendations to stabilize the resident's weight, there was no documentation that the Physician or PA was made aware of the initial or ongoing weight loss. Interviews with the nursing staff, dietician, and PA revealed a lack of communication and documentation regarding the resident's weight changes. The facility's policies required notifying the attending physician of significant changes in a resident's condition, including weight loss. However, the facility failed to adhere to these policies for both residents. The lack of documentation and communication with the Physician or PA regarding the residents' significant weight loss was confirmed through interviews with the nursing staff, dietician, and PA, highlighting a deficiency in the facility's protocol for managing changes in residents' conditions.
Failure to Complete SCSA for Resident with Decline in ADLs and New Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (SCSA) assessment for a resident who experienced a decline in activities of daily living (ADLs) and developed a new pressure ulcer. The resident, admitted in November 2024 with diagnoses including dementia and an intertrochanteric fracture of the right femur, initially required supervision for oral hygiene, partial assistance for upper body dressing, substantial assistance for lower body dressing, and had no pressure ulcers. By February 2025, the resident required substantial assistance for oral hygiene, was dependent for upper and lower body dressing, and had developed an unstageable pressure ulcer. Despite these changes, no SCSA was completed between the November 2024 and February 2025 assessments. The MDS Nurse acknowledged that the January 2025 documentation reflected the resident's decline and the development of the pressure ulcer, and confirmed that an SCSA should have been completed but was not.
Failure to Administer Insulin Within Prescribed Time Frame
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering medication to a resident with Type 2 Diabetes. The resident was prescribed Lantus SoloStar and Humalog KwikPen insulin to be administered at specific times. However, the facility did not ensure that these medications were administered within the one-hour window before or after the prescribed times. Specifically, there were multiple instances where both types of insulin were administered outside the acceptable time frame, as documented in the Location of Administration Reports for January and February 2025. Interviews with nursing staff, including a nurse, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), revealed that the staff was aware of the requirement to administer insulin within the specified time frame. However, there was a lack of proper documentation and communication when insulin was administered outside the acceptable time frame. The ADON acknowledged uncertainty about whether the medication was administered outside the time frame or if there was a failure in documentation, indicating a need for staff education on proper medication administration and documentation practices.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #35, who experienced significant weight loss. Resident #35 was admitted with multiple diagnoses, including diabetes, lung cancer, COPD, C-Diff, chronic kidney disease, anxiety, and depression. Despite being cognitively intact and requiring only setup or cleanup assistance with eating, the resident experienced a weight loss of over 17% from July 2024 to February 2025, which was not adequately addressed by the facility. The facility's policy on weighing and measuring residents indicates that a weight loss of greater than 10% in six months is severe. Resident #35's weight loss exceeded this threshold, yet the facility did not implement effective nutritional interventions. Although the resident was prescribed ProHeal Liquid Protein, they refused it 31 times out of 55 opportunities, and the supplement was discontinued without alternative interventions being offered. The resident expressed dissatisfaction with the facility's food and mentioned relying on soup and snacks brought by family. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's nutritional needs and weight loss. The dietician was unaware of the frequent refusals of the ProHeal supplement and did not document conversations with the provider about the resident's weight loss. The physician assistant also indicated that they were not informed of the significant weight loss or the discontinuation of the nutritional supplement. The facility's dietary staff mentioned limitations in ordering supplemental foods, which may have contributed to the lack of alternative nutritional interventions for the resident.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required. This deficiency was identified for one resident, who was admitted with a diagnosis of Vascular Dementia. The Pharmacist's Progress Notes indicated that recommendations were made on two occasions, but the medical record did not provide evidence of these Pharmacy Recommendations or the Clinical Pharmacy Reports. Furthermore, there was no indication that the Physician had reviewed these recommendations. During the survey, the Director of Nursing was unable to provide additional information or evidence of the Physician's review of the Pharmacy Recommendations.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to provide continuity of care related to hospice services for Resident #42, who was admitted with a diagnosis of cerebral infarction. The facility did not designate a member of the interdisciplinary team (IDT) to coordinate care with hospice representatives, nor did it obtain or maintain the most recent hospice plan of care for the resident. This lack of coordination and documentation was evident during interviews with the social worker, the Director of Nursing (DON), and Nurse #2, who all expressed uncertainty about who was responsible for maintaining hospice documentation in the resident's hospice binder. The hospice nursing facility services agreement required the facility to develop procedures for communication and documentation to ensure patient needs are met 24/7, and to have patient care policies consistent with hospice protocols. However, the facility did not have a designated staff member to ensure hospice documentation was maintained, leading to the absence of the hospice plan of care in Resident #42's binder. The DON and Nurse #2 both indicated that they expected hospice staff to maintain the documentation, but this expectation was not met, resulting in incomplete records for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices across two units, leading to multiple deficiencies. For a resident on the North Unit, staff did not utilize Enhanced Barrier Precautions (EBP) despite the resident having a Jejunostomy tube and a leaking Jackson Pratt drain. A rehabilitation staff member was observed assisting the resident without wearing the required gown, only wearing gloves, and was unaware of the EBP requirement for this resident. Another resident on the North Unit, diagnosed with C-Diff, was not provided with proper Contact Precautions. A CNA entered the resident's room without performing hand hygiene or donning the required gown and gloves, despite signage indicating these precautions were necessary. The CNA acknowledged the oversight during an interview. On the [NAME] Unit, a nurse failed to clean and disinfect scissors after using them to remove a soiled dressing from a resident with dementia and a femur fracture. The scissors were then used to cut new dressing materials, potentially contaminating them. Additionally, a resident on the North Unit with symptoms of a transmissible infection was not placed on Transmission-Based Precautions while awaiting test results. The resident was later observed without proper isolation measures, and staff did not have access to necessary PPE, such as eye protection, which was not available in the PPE bin or at the nurses' station.
Failure to Maintain Safe Wheelchair Condition
Penalty
Summary
The facility failed to maintain patient care equipment in a safe operating condition for a resident who was admitted with diagnoses including Cerebral Infarct and Rheumatoid Arthritis. The resident, who had moderate cognitive impairment and was dependent on transfers, was observed sitting in a wheelchair with a missing left armrest. This left a metal bar and an exposed screw, posing a risk of injury to the resident. During observations and interviews, it was revealed that the missing armrest had not been reported to maintenance, despite the facility's policy requiring staff to report broken equipment immediately. The Maintenance Director confirmed that no work order had been received prior to the surveyor's observation, indicating a lapse in communication and adherence to protocol. The exposed screw and missing armrest were acknowledged as a concern due to the potential for injury.
Inaccurate MDS Coding for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for a resident, specifically regarding weight loss. The resident, who was admitted in July 2024, had multiple diagnoses including diabetes, lung cancer, COPD, C-Diff, CKD, anxiety, and depression. A review of the resident's weight summary from July 24, 2024, to December 1, 2024, showed a significant weight loss of 16.20% over six months. However, the MDS assessment dated December 16, 2024, inaccurately indicated that the resident did not experience a weight loss of 5% or more in the last month or 10% or more in the last six months. During interviews, the MDS Nurse acknowledged that the weight loss should have been coded as significant, as the resident experienced a weight loss of over 10% in six months. The MDS Nurse explained that the Dietician is responsible for completing section K of the MDS, where weight information is documented. The nurse also noted that sometimes staff complete required sections without fully signing off, leading her to finalize them. The failure to accurately code the MDS assessment was attributed to not using the most recent weight obtained within 30 days of the assessment date.
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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