Continuing Care At Brooksby Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Peabody, Massachusetts.
- Location
- 400 Brooksby Village Drive, Peabody, Massachusetts 01960
- CMS Provider Number
- 225767
- Inspections on file
- 29
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Continuing Care At Brooksby Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer's Disease was found with a bed sheet tightly wrapped around their body, restricting access to their incontinent brief. A CNA applied the sheet without medical order or inclusion in the care plan, intending to prevent the resident from accessing feces after episodes of diarrhea. The resident was unable to remove the restraint independently, and staff confirmed this use of a physical restraint was not authorized.
A resident with moderate cognitive impairment reported being physically abused by a CNA, resulting in a bruise. The nurse reported the incident to the Nurse Supervisor, but the Supervisor failed to immediately report it as an abuse allegation to the DON, as required by the facility's policy.
A resident with a complex medical history experienced worsening of a right lower extremity wound due to the facility's failure to reschedule a wound clinic appointment, improper application of Dakin's solution without a protective barrier, and lack of weekly wound assessments. Additionally, coban was applied without a physician's order, resulting in a new blister. These actions did not adhere to professional standards of practice.
The facility did not conduct mandatory QAPI training for its staff. A review of the Facility Assessment and employee education records showed no documentation of QAPI training for 15 direct care employees, including CNAs and licensed nurses. The Administrator confirmed the absence of such training.
The facility failed to ensure a dignified experience for residents by allowing staff to speak a foreign language in the presence of primarily English-speaking residents on the Terrace unit. Observations and interviews confirmed that staff conversed in a foreign language in common and dining areas, despite the Director of Nursing's acknowledgment that resident care areas are English-speaking only.
The facility failed to provide adequate care for residents with pressure ulcers, as observed in four cases. A resident with a stage 4 ulcer had an air mattress set incorrectly, while another with a stage 2 ulcer lacked a physician's order for an air mattress and was not assessed weekly. A third resident's stage 2 ulcer was not documented in weekly assessments, and a fourth resident's deep tissue injury was not monitored as required. The DON and staff acknowledged these deficiencies.
The facility failed to ensure nursing staff were trained and demonstrated competencies in wound care, as required by the Facility Assessment. The assessment did not specify necessary competencies, and multiple deficiencies were identified during the survey, including failures in wound assessment, treatment, and communication with providers. A review showed 7 out of 10 nurses lacked completed wound care competencies since hire, and the DON was unaware of these lapses.
The facility did not conduct a thorough assessment to identify necessary nursing competencies for resident care. The assessment lacked specific competencies, and interviews revealed that both the DON and Administrator were unaware of the required competencies, with the DON unable to provide a list during the survey.
A resident with moderate cognitive impairment and a care plan requiring meal supervision was repeatedly observed eating without staff assistance, leading to spills and potential safety risks. Staff interviews revealed inconsistencies in understanding the resident's needs, contributing to the deficiency.
Two residents in a facility experienced deficiencies in fall prevention measures. A resident with Alzheimer's fell and fractured a wrist due to the absence of a urinal, contrary to their care plan. Another resident with a history of falls lacked non-skid strips and a fall mat, as required by their care plan. Staff interviews confirmed these oversights, highlighting a failure to adhere to the facility's fall management policy.
A resident with obstructive sleep apnea used a CPAP machine without a physician's order, as required by professional standards. The facility's policy did not specify the need for such an order, leading to the oversight. Staff acknowledged the error, noting the CPAP was used at night and sometimes during naps, but assistance was inconsistent.
The facility failed to ensure transmission-based precautions were followed when a nurse and a nurse practitioner did not wear a precaution gown during wound care for a resident on enhanced barrier precautions. Despite signage indicating the need for gowns and gloves, they only wore gloves while treating a resident with a chronic wound and pressure ulcer. The DON confirmed that gowns should have been worn as per the facility's policy.
Unauthorized Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) wrapped a bed sheet around a resident with severe cognitive impairment, from under the chest to below the buttocks, to prevent the resident from accessing the area of their incontinent brief. The resident, diagnosed with Alzheimer's Disease and requiring substantial to maximal assistance with toileting hygiene, was found by another CNA in the morning with the sheet tightly wrapped around their body. The resident was unable to remove the sheet independently due to cognitive and physical limitations, and the sheet restricted the resident's ability to touch their mid-torso and brief area. The facility's abuse prevention policy defines misuse of restraints as any material attached or adjacent to a resident's body that cannot be easily removed and restricts freedom of movement or normal access to one's body, especially when not ordered by a medical provider or included in the plan of care. The resident's plan of care did not include the use of restraints, and there was no medical order for such an intervention. The CNA who applied the restraint did not notify the nurse or any other staff about the resident's behavior or the use of the bed sheet as a restraint. Interviews with staff confirmed that the CNA wrapped the sheet to prevent the resident from accessing feces in the brief, following episodes of diarrhea and fecal smearing. The incident was discovered during morning care, and staff agreed that the resident would not have been able to remove the sheet independently. The use of the bed sheet in this manner was not authorized and constituted a physical restraint, contrary to facility policy and regulatory requirements.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to ensure that staff implemented and followed their abuse policy when a resident reported an allegation of physical abuse. On December 12, 2024, a nurse noticed a bruise on a resident's right arm during early morning care. The resident, who was moderately cognitively impaired and required assistance from two staff members, reported that a CNA had been rough and pushed them the previous evening. The nurse immediately reported the incident to the Nurse Supervisor, as per the facility's policy. However, the Nurse Supervisor did not immediately report the abuse allegation to the Director of Nursing (DON) as required by the facility's abuse policy. Instead, the Nurse Supervisor reported the incident as a concern about care provided, not as an abuse allegation, to the DON at 8:30 A.M. The DON later determined that the incident was indeed an allegation of abuse after reviewing the nursing documentation at 2:30 P.M. This delay in reporting the abuse allegation was a failure to adhere to the facility's policy, which mandates immediate reporting of such incidents.
Failure to Provide Appropriate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a deteriorating right lower extremity wound. The resident, who was cognitively intact and required substantial assistance, had a history of diabetes, end-stage renal disease, and a traumatic wound. Despite multiple orders from a Nurse Practitioner to reschedule a wound clinic appointment due to the worsening condition of the wound, the facility did not ensure the appointment was made. The unit secretary responsible for scheduling was on vacation, and no one covered her duties, leading to confusion and a lack of follow-up on the resident's care needs. Additionally, the facility did not adhere to the physician's order regarding the application of z-guard before soaking the wound in Dakin's solution. This oversight resulted in the resident experiencing pain and further deterioration of the wound. Nurses frequently applied the z-guard after the Dakin's solution, contrary to the specified order, and were unaware of the potential damage Dakin's solution could cause to healthy tissue. The Director of Nursing acknowledged that the solution is caustic and painful, emphasizing the importance of following the physician's order to protect the surrounding skin. The facility also failed to conduct weekly assessments and measurements of the resident's wound as required by the care plan. There was a significant gap between documented wound assessments, during which the wound worsened. Furthermore, the facility applied coban without a physician's order, leading to the development of a new blister on the resident's lower extremity. The improper use of coban under an ace wrap was identified as a contributing factor to the blister, highlighting a lack of adherence to professional standards of practice.
Failure to Implement Mandatory QAPI Training
Penalty
Summary
The facility failed to implement mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for its staff. A review of the Facility Assessment dated November 1, 2024, did not indicate any mandatory QAPI training. Additionally, an examination of the education records for 15 direct care employees, including 5 certified nurse assistants (CNAs) and 10 licensed nurses, revealed that none had documentation of completing QAPI training during their employment. During an interview on December 23, 2024, the Administrator confirmed that the facility does not provide any QAPI training to employees.
Failure to Ensure Dignified Experience for Residents
Penalty
Summary
The facility failed to provide a dignified experience for residents on the Terrace unit by allowing staff to speak a foreign language in the presence of primarily English-speaking residents. This was observed during a resident group meeting where three residents expressed that staff spoke in a foreign language in front of them. Additionally, a surveyor observed staff members conversing in a foreign language in the common area and dining area of the Terrace unit, where residents were present and within earshot. Further observations included staff speaking a foreign language while providing feeding assistance to a resident, with other residents at the table and nearby. A resident responded by stating they did not understand the language being spoken. Interviews with a nurse and the Director of Nursing confirmed that staff had been speaking in a foreign language in resident care areas, which are designated as English-speaking only. The Director of Nursing acknowledged witnessing this behavior in the past.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in four cases. Resident #30, who had a stage 4 pressure ulcer, was found with an air mattress set incorrectly at 260 lbs instead of the required 140 lbs, which was not adjusted despite multiple observations. This incorrect setting was acknowledged by the nursing staff and the Director of Nursing (DON), who confirmed that the air mattress should be set to the resident's weight and checked every shift. Resident #52, admitted with a stage 2 pressure ulcer, did not have a physician's order for an air mattress, and the ulcer was not assessed or measured weekly as required. The treatment administration record (TAR) lacked documentation of the ulcer's measurements, and the resident was not included in the facility's risk meeting notes or pressure ulcer audit. The DON and nursing staff acknowledged the lack of documentation and the absence of a physician's order for the air mattress. Resident #1, with a stage 2 pressure injury, did not have weekly skin assessments documented after the injury was identified. The nursing staff and Nurse Practitioner (NP) admitted that wound rounds had not been conducted due to staffing changes, and the resident's condition was not discussed in risk meetings. Similarly, Resident #12, with a deep tissue injury, did not have weekly wound assessments documented, and the wound was not monitored as required. The DON confirmed that wounds should be assessed weekly and documented, but this was not done for Resident #12.
Deficiency in Nursing Staff Competency for Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies for wound care, as outlined in the Facility Assessment. The assessment, dated 11/21/24, indicated that the facility offered services related to skin integrity, including pressure injury prevention and wound care. However, it did not specify the required nurse competencies for these services. The facility's policy on 'Health Services Education and Training' required supervisors to validate employee knowledge and ability through competency reviews, but this was not effectively implemented. During the recertification survey, multiple deficiencies in wound care were identified, including failures to assess and measure wounds weekly, implement enhanced barrier precautions, follow physician's orders for wound treatments, notify providers of new or changing wounds, and complete weekly skin checks. A review of staff education files revealed that 7 out of 10 licensed nurses responsible for wound care had not completed wound competencies since their hire. The Director of Nursing, who was covering the vacant staff development nurse position, was unaware of these lapses. The Administrator expected that all nurses would have completed clinical competencies, including wound care, upon hire.
Failure to Identify and Implement Necessary Nursing Competencies
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated 11/21/24, did not specify the nursing competencies required to provide the services and care offered by the facility. Additionally, the facility's policy on 'Health Services Education and Training' from April 2023 indicated that supervisors and managers should complete competency reviews to validate employee knowledge and ability to perform tasks. However, this was not effectively implemented. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of awareness regarding the inclusion of nursing competencies in the facility assessment. The DON, who was temporarily covering the staff development nurse position, was unaware of the competencies required upon hire and could not provide a list of specific competencies during the survey. Similarly, the Administrator was unable to locate a list of required competencies, indicating a disconnect between the facility's practices and the guidance from the home office.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision for Resident #32 during meals, despite the resident's care plan indicating a need for such supervision. Resident #32, who was admitted with conditions including atrial fibrillation, muscle weakness, and moderate cognitive impairment, was observed multiple times without staff supervision while eating. The resident's care plan and occupational therapy evaluations clearly stated the requirement for supervision during meals to ensure safety and proper assistance. However, observations on several occasions showed the resident eating alone, with food and drink spilled, and no staff present to assist or supervise. Interviews with facility staff revealed inconsistencies in understanding and implementing the resident's care plan. CNA #3 acknowledged the need for supervision but mentioned only watching from the hallway, while CNA #2 incorrectly stated that the resident did not require supervision. Nurse #7 also misunderstood the resident's needs, suggesting that supervision was not currently necessary but might be in the future. The Director of Nursing confirmed that the care plan should be followed, emphasizing the importance of supervision to prevent choking and ensure the resident is seated upright while eating. This lack of adherence to the care plan and miscommunication among staff led to the deficiency in providing adequate care for Resident #32.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure an environment free from accidents and hazards for two residents, leading to deficiencies in their care. Resident #31, who has Alzheimer's Disease and severe cognitive impairment, fell and sustained a wrist fracture while attempting to self-toilet. The resident's care plan required a urinal to be kept within reach of the bed, but observations revealed that the urinal was not present, and there was no documentation of the resident refusing the urinal. Interviews with staff confirmed the expectation that the urinal should be available as per the care plan. Resident #32, with moderate cognitive impairment and a history of repeated falls, was observed without the necessary fall prevention measures in place. The resident's care plan included the use of non-skid strips and a fall mat next to the bed, but these were not observed during multiple visits. Despite having a history of falls, the care plan and physician's orders did not reflect the necessary interventions, and staff interviews indicated uncertainty about the accuracy of the care plan documentation. The facility's policy on fall management emphasizes individualized care plans and the implementation of interventions to prevent falls. However, the lack of adherence to these plans for Residents #31 and #32 resulted in preventable accidents. The Director of Nursing acknowledged the expectation for interventions to be in place and reviewed the process for updating care plans following falls, but the deficiencies observed indicate a failure to implement these procedures effectively.
Failure to Obtain Physician's Order for CPAP Use
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident diagnosed with obstructive sleep apnea. The resident was admitted to the facility with a CPAP machine, which is used to treat sleep apnea, but the facility did not obtain a physician's order for its use. Despite the resident using the CPAP machine at night and expressing a preference to use it during daytime naps, there was no documentation of a physician's order in the resident's active orders. The facility's policy on respiratory equipment did not specify the need for a physician's order for CPAP use, contributing to the oversight. Observations and interviews revealed that the resident sometimes could not use the CPAP machine due to a lack of assistance from staff, such as ensuring the machine had water in its chamber. Staff members, including nurses and the Director of Nursing, acknowledged that a physician's order should have been obtained when the CPAP machine was brought in, but this step was missed. The oversight was evident as the CPAP machine was observed on the resident's bedside table, and staff were aware of its presence, yet failed to ensure the necessary orders were in place.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that transmission-based precautions were followed to prevent the spread of infections. Specifically, the deficiency occurred when Nurse #6 and Nurse Practitioner (NP) #1 did not don a precaution gown while performing wound care for a resident on enhanced barrier precautions. The resident had a chronic traumatic wound with a large amount of drainage and an unstageable pressure ulcer. Despite the presence of a sign at the resident's doorway indicating the need for enhanced barrier precautions, both staff members wore only gloves during the wound dressing change. During a follow-up interview, Nurse #6 acknowledged that the resident was on enhanced barrier precautions and admitted that she should have worn a gown during the wound care but did not. The Director of Nursing (DON) confirmed that enhanced barrier precautions, including the use of a precaution gown, are required for wound care and dressing changes for wounds with drainage or that are chronic. The DON stated that a precaution gown should have been worn during the wound care for any resident with a sign on the doorway indicating the requirement for enhanced barrier precautions.
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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