Clifton Rehabilitation Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Somerset, Massachusetts.
- Location
- 500 Wilbur Avenue, Somerset, Massachusetts 02725
- CMS Provider Number
- 225402
- Inspections on file
- 24
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Clifton Rehabilitation Nursing Center during CMS and state inspections, most recent first.
The facility did not maintain an effective infection prevention and control program, specifically failing to implement a comprehensive water management plan to prevent Legionella growth. Water testing revealed positive results for L. pneumophila in two areas, but no mitigation or follow-up actions were taken. Facility leadership was unaware of the positive results, and water temperatures in resident areas were kept below recommended levels for Legionella control.
The facility failed to address ongoing concerns from the Resident Council about cold food and not receiving selected menu items. Despite repeated complaints from residents, the Food Service Director and Dietitian did not investigate or document responses to these issues, leaving them unresolved.
The facility failed to develop and implement individualized care plans for four residents, leading to deficiencies in addressing their specific needs. One resident did not have a care plan for insomnia treatment, two residents at high risk for falls did not have prescribed fall prevention interventions in place, and another resident with lymphedema did not have a care plan for the use of a compression sleeve and glove.
The facility failed to prepare and serve meals that were palatable and at safe temperatures. Multiple residents reported issues with cold and flavorless food, which were confirmed by test trays showing inappropriate food and drink temperatures. The FSD and Administrator acknowledged these deficiencies.
The facility failed to follow food safety and sanitation policies, leading to the potential spread of foodborne illness. Observations revealed undated and unlabeled food items, expired food, and unclean microwaves in three nourishment kitchenettes. Interviews with staff confirmed that these issues were not in line with the facility's policies.
A nurse failed to follow proper infection control practices, including hand hygiene between resident care and glove changes, and proper disinfection of blood glucose monitoring equipment. The nurse did not perform hand hygiene as required and improperly disinfected the glucometer by wrapping it in a wet wipe instead of allowing it to air dry.
The facility failed to address and document grievances raised by residents and their family members regarding long call light wait times and missing items. Staff did not follow the facility's grievance policy, resulting in unresolved issues and a lack of accountability.
The facility failed to provide necessary respiratory care and services for three residents by not ensuring that oxygen and BiPAP tubing were changed and stored in a sanitary manner as per facility policy. Observations and interviews confirmed that the required standards were not met.
A facility failed to ensure a resident had a documented rationale and appropriate monitoring for the ongoing PRN use of Trazodone. The resident's medical record did not indicate a diagnosis of insomnia, and care plans did not reflect the use of psychotropic medications for insomnia or any non-pharmacological interventions. The medication's purpose was inconsistently documented, and the resident used the medication infrequently, suggesting it might not be necessary.
The facility failed to ensure proper storage and administration of medications for three residents. Medications were left at the bedside without proper consent or evaluation for self-administration, contrary to the residents' care plans and physician's orders.
Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the management of water systems to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of facility policies and CMS guidance revealed requirements for a comprehensive water management plan, including risk assessments, temperature controls, routine maintenance, and protocols for testing and responding to positive Legionella results. However, the facility's water management plan did not identify areas at risk for Legionella growth or outline mitigation strategies in the event of positive test results. Laboratory testing of the facility's water system detected L. pneumophila in two locations, with results of 47 MPN/ml and 10 MPN/ml, which are considered cause for concern according to CDC guidelines. Despite these findings, there was no evidence that the facility took any mitigation actions or conducted further testing in response to the positive results. The Director of Maintenance was unaware of the positive Legionella results and did not implement any temperature controls or other measures specifically aimed at preventing Legionella growth in the resident water supply. Interviews with facility leadership, including the Administrator and Director of Maintenance, confirmed a lack of awareness regarding the positive Legionella test results and the absence of any follow-up actions or environmental assessments. The facility's water temperature logs indicated that hot water in resident areas was maintained between 109.9°F and 111.4°F, below the recommended levels for Legionella control. The facility's water management plan and practices did not align with federal and industry standards for Legionella prevention, contributing to the identified deficiency.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to act promptly and demonstrate their response to concerns brought forth by the Resident Council. From November 2023 to March 2024, residents repeatedly voiced concerns about receiving cold food and not getting their selected menu items during Resident Council meetings. Despite these ongoing complaints, there was no documentation or evidence that the facility resolved these issues. The Food Service Director (FSD) and the Dietitian attended some of the meetings but did not conduct any audits or investigations, nor did they provide documented responses to the residents' concerns. The Activity Director (AD) acknowledged that similar food-related concerns were raised month after month without resolution. Interviews with the FSD, Dietitian, and AD revealed that the facility lacked a process for addressing and documenting responses to Resident Council concerns. The FSD admitted to telling residents to ask nursing staff to reheat their food but did not take further action to investigate or resolve the issues. The Dietitian was unaware of the need to investigate the concerns and did not follow up. The AD confirmed that the food-related issues remained unresolved and that there was no formal process for providing responses to the Resident Council. Resident #36, who regularly attended the meetings, confirmed that the concerns about cold food and not receiving preferred menu items were ongoing and unresolved.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized resident-centered care plans for four residents, leading to deficiencies in addressing their specific needs. For Resident #78, the facility did not create a care plan for the treatment of insomnia using PRN Trazodone, despite the resident having a history of insomnia and receiving the medication multiple times. The care plans in place did not reflect the resident's use of psychotropic medications for insomnia, and the issue was confirmed by both the Unit Manager and the Director of Nurses (DON). Resident #29, who had a history of falls and was at high risk for further falls, did not have the prescribed fall prevention interventions implemented. The care plan required bright colored tape on the call light for better visibility and anti-slip material on the wheelchair, but these were not in place during multiple observations. The resident confirmed the absence of the bright colored tape, and the Unit Manager and DON acknowledged the failure to follow the care plan. Resident #74, also at high risk for falls, did not have the required anti-slip material or Dycem on the chair cushion as specified in the care plan. Observations over several days confirmed the absence of these interventions, and the Unit Manager and DON admitted that the care plan was not being followed. Additionally, Resident #1, who had lymphedema, did not have a care plan for the use of a compression sleeve and glove, despite recommendations from a Lymphedema Clinic. Interviews with staff revealed inconsistencies in the application of the compression garments, and the Unit Manager admitted the care plan was not updated to reflect the resident's needs.
Deficiency in Meal Preparation and Serving
Penalty
Summary
The facility failed to prepare and serve meals in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. During initial resident screening, multiple residents expressed concerns about the food being cold, lacking flavor, and having a strange consistency. These concerns were consistently documented in Resident Council Meeting Minutes over several months, indicating ongoing issues with food quality and temperature. Specific complaints included cold eggs, cold coffee and tea, salty or peppery food, lumpy potatoes, and withered lettuce in salads. The Food Service Director (FSD) was aware of these concerns and attended Resident Council Meetings when invited. Test trays conducted by the surveyor confirmed these issues. A lunch test tray showed that herbed chicken, wax beans, and whole milk were served at inappropriate temperatures, with the wax beans being cold and flavorless. A breakfast test tray revealed that French toast, scrambled eggs, and drinks were served at temperatures that were too cool or warm. The FSD acknowledged these deficiencies, stating that meals should be warm and flavorful when delivered to residents. The Administrator also reviewed the findings and agreed that items should be held to appropriate temperatures and be flavorful when served.
Failure to Follow Food Safety and Sanitation Policies
Penalty
Summary
The facility failed to follow their policy and professional standards of practice for food safety and sanitation, leading to the potential spread of foodborne illness among residents. Specifically, the facility did not properly label and date food products and failed to maintain clean equipment in three nourishment kitchenettes. Observations revealed multiple instances of undated and unlabeled food items, expired food, and unclean microwaves with food particle splatter and stains in the resident refrigerators and nourishment kitchenettes on the [NAME] Two Unit, East Two Unit, and [NAME] One Unit. During interviews, the Food Service Director (FSD) confirmed that the nourishment kitchenettes and resident refrigerators are supposed to be stocked and cleaned by the kitchen's nourishment aide three times a day. The FSD acknowledged that food items brought in from outside should be labeled with the resident's name and the date they were brought in, and any items that are not properly labeled or expired should be removed. Certified Nurse Assistant (CNA) #6 also stated that food items brought to the facility must be labeled and dated, with the resident's name and the date the item was put in the refrigerator. The Administrator confirmed that all nourishment kitchenettes should always remain clean and that food products brought into the facility by visitors should not be expired and should be properly labeled and dated. Despite these policies, the surveyor's observations indicated that these standards were not being consistently followed, resulting in the presence of expired and improperly labeled food items, as well as unclean equipment in the nourishment kitchenettes and resident refrigerators.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow proper infection control practices, specifically in hand hygiene and the disinfection of blood glucose monitoring equipment. During an afternoon medication pass, a nurse was observed not performing hand hygiene between resident care and glove changes. The nurse handled various items, including medication containers, a computer keyboard, and medication cards, without washing hands between tasks. Additionally, the nurse did not perform hand hygiene after removing gloves and before moving the medication cart to another room. These actions were contrary to the facility's hand hygiene policy, which mandates hand hygiene between resident contacts, after handling contaminated objects, and before and after glove changes, among other instances. The nurse also failed to properly disinfect blood glucose monitoring equipment. The facility's policy requires the glucometer to be cleaned and disinfected with a wipe pre-saturated with an EPA-registered healthcare disinfectant, allowing it to air dry for two minutes. However, the nurse was observed cleaning the glucometer by wiping it down and wrapping it in the wet wipe, then placing it on top of the medication cart without allowing it to air dry. The nurse then moved the medication cart to another room without performing hand hygiene. This practice was inconsistent with the facility's policy and the manufacturer's instructions for the disinfectant wipes. Interviews with the nurse, unit manager, and Director of Nursing (DON) confirmed that the observed practices did not align with the facility's infection control policies. The nurse admitted to not performing hand hygiene as required and to wrapping the glucometer in the disinfectant wipe instead of allowing it to air dry. The unit manager and DON both stated that hand hygiene should be performed between every resident and before and after glove changes, and that the glucometer should be allowed to air dry for two minutes after disinfection to ensure proper sanitization.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to properly address and document grievances raised by residents and their family members. Resident #121 and their family member voiced concerns about long call light wait times during a care plan meeting and subsequent interactions with the Unit Manager and Director of Nurses. Despite these concerns being raised, no grievance forms were completed, and the issues were not documented or resolved promptly. The Director of Nurses and Unit Manager failed to recall specific details of the complaints and did not follow the facility's grievance policy, which mandates the recording and resolution of grievances. Similarly, Resident #86 and their family member reported missing items, including money, during a care plan meeting. The Unit Manager acknowledged the concerns but did not complete a Missing Item Report, as required by the facility's policy. The Social Worker and Unit Manager both failed to document the grievances, and the Director of Nurses confirmed that the process for handling missing items was not followed. The facility's grievance binder did not contain any forms related to these incidents, indicating a systemic failure to address and document grievances. The facility's policy on resident and family grievances requires prompt efforts to resolve complaints and proper documentation of all grievances. However, the staff's failure to adhere to this policy resulted in unresolved issues and a lack of accountability. The deficiencies highlight the need for better adherence to grievance procedures to ensure residents' concerns are addressed and resolved in a timely manner.
Failure to Provide Necessary Respiratory Care and Services
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents. For Resident #4, the facility did not ensure that oxygen tubing was changed and stored in a plastic bag when not in use, as per facility policy. Observations over several days showed that the nasal cannula tubing attached to the portable oxygen tank was lying across the back of the wheelchair without a storage bag. Interviews with the nursing staff and the Director of Nursing confirmed that the tubing should be changed weekly and stored in a bag when not in use, but this standard was not met for Resident #4. For Resident #221, the facility did not store the BiPAP respiratory tubing and nasal pillow in a sanitary way when not in use. Observations revealed that the BiPAP tubing and nasal pillow were hanging over the siderail of the resident's bed and not stored in a plastic respiratory bag. The resident confirmed that staff cleaned the equipment but did not provide a storage bag. Interviews with the Unit Manager and the Director of Nursing indicated that the facility's protocol was to store BiPAP equipment in a respiratory bag when not in use, but this was not followed for Resident #221. For Resident #32, the facility did not ensure that oxygen tubing was changed and stored in a plastic bag when not in use. Observations showed that the oxygen machine's nasal cannula and tubing were not stored in a bag and were not dated correctly. Interviews with the resident and nursing staff confirmed that the tubing should be changed weekly and stored in a bag when not in use, but this was not done for Resident #32.
Lack of Documentation and Monitoring for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident had a documented rationale and appropriate monitoring for the ongoing, as-needed (PRN) use of a psychotropic medication. The resident, who was admitted with diagnoses including mood disorder, depression, delusional disorder, and hallucinations, had a PRN Trazodone order for insomnia that was routinely re-evaluated and extended without proper documentation. The medical record did not indicate a diagnosis of insomnia, nor did it show that the resident was being monitored for sleeplessness or insomnia. Additionally, the care plans did not reflect the use of psychotropic medications for insomnia or any non-pharmacological interventions attempted to assist the resident in getting restful sleep without medication. The psychoactive PRN medication evaluation forms showed inconsistencies and lacked a rationale for the continued use of the PRN medication. The forms initially indicated the medication was for insomnia but later changed to anxiety without explanation. The medication administration record (MAR) indicated infrequent use of the PRN Trazodone, suggesting it might not be necessary. The Unit Manager and Director of Nurses (DON) acknowledged the lack of documented rationale and the potential error in changing the medication's purpose from insomnia to anxiety. The progress notes and physician notes from February through April did not provide evidence of a documented diagnosis of insomnia or a clinical rationale for the ongoing PRN Trazodone use. The DON concluded that the medication was likely no longer necessary for the resident, and there was no documentation by the physician to indicate that the benefits of the medication outweighed the risks.
Improper Storage and Administration of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and administered in accordance with professional principles. For Resident #8, morning medications were left at the bedside instead of being administered under direct supervision. The resident, who was cognitively intact, had no care plan or physician's order to self-administer medications, yet the medications were signed off as administered by the nurse. For Resident #106, Saline 0.65% Nasal Spray was left at the bedside, and the resident did not have a self-administration consent or evaluation. The nurse admitted that the resident probably self-administers the nasal spray when feeling dry, despite the resident's preference for medication administration by nursing staff and the absence of a care plan or physician's order for self-administration. Resident #112 had Fluticasone Propionate Nasal Spray stored at the bedside without a self-administration consent or evaluation. The resident's care plan and physician's orders did not indicate self-administration, yet the nasal spray was observed on the nightstand. The Director of Nurses confirmed that none of these residents should have medications at their bedside and that all medications should be administered under direct observation by the nurse.
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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