Country Gardens Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Swansea, Massachusetts.
- Location
- 2045 Grand Army Highway, Swansea, Massachusetts 02777
- CMS Provider Number
- 225185
- Inspections on file
- 25
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Country Gardens Health And Rehabilitation Center during CMS and state inspections, most recent first.
Nursing staff did not notify the Health Care Agent of a resident with an activated Health Care Proxy about significant changes in condition, including a new diet order, a blister requiring treatment, and an episode of unresponsiveness that led to new physician orders. The facility's policy required prompt notification and documentation, but there was no evidence that the HCA was informed, and the HCA only learned of these events after reviewing the medical record.
A resident with complex medical needs was readmitted from the hospital with new orders for a dysphagia carbohydrate-consistent diet, but due to nursing staff oversight, the new diet order was not transcribed or communicated to dietary services. As a result, the resident received a regular texture diet for two days until the error was identified and corrected.
A resident with multiple diagnoses, including dementia and diabetes, was readmitted from the hospital with new diet instructions for a Dysphagia Carbohydrate Consistent diet. Nursing staff failed to transcribe the new diet order into the medical record, instead continuing the previous diet order. The DON confirmed that the expectation was for all discharge orders to be reviewed and accurately entered, but the new order was missed, resulting in incomplete documentation.
The facility did not submit required direct care staffing data to CMS for an entire quarter, as confirmed by review of PBJ and CASPER reports. A change in the corporate HR position led to unawareness of the missed submission, and attempts to submit the data after the deadline were unsuccessful, resulting in a one-star staffing rating.
The facility failed to maintain an effective infection prevention and control program, including incomplete infection surveillance records, lack of proper outbreak management documentation, and unsanitary medication administration practices. A nurse administered a medication after it was dropped on an unclean surface, and the facility's infection surveillance logs were missing critical information such as symptoms, onset dates, and culture results. Additionally, the facility did not adequately document contact tracing or testing during a COVID-19 outbreak.
The facility did not ensure accurate documentation of PRN opioid administration for a resident, with multiple instances missing from the EMAR compared to the Narcotic Book, and failed to maintain consistency between MOLST forms and medical records for three residents regarding advance directives. Staff interviews confirmed lapses in documentation, and the DON acknowledged the expectation for accurate and complete records.
The facility did not ensure its QAA Committee developed and maintained a comprehensive, data-driven QAPI program. Leadership initiated projects to improve the grievance process and incident report completion without using baseline data, benchmarks, or measurable metrics, and lacked training on systematic quality improvement methods. The Director of Operations confirmed that required processes were not in place, resulting in a deficiency.
The facility did not ensure that four newly hired staff members were offered the 2024-2025 COVID-19 vaccine or that their vaccination status was properly documented, as required by CDC guidance. Personnel files lacked evidence of vaccine offers or declinations, and interviews confirmed that the facility did not provide the updated vaccine to new hires.
A resident with a neurogenic bladder and an indwelling Foley catheter was repeatedly observed with an uncovered urinary drainage bag visible from the doorway. Despite facility policy requiring privacy and staff acknowledgment that the bag should be covered, the resident's dignity was not maintained.
A flip chart containing residents' private health information and ADL schedules was left open and facing outward on a nurses' station desk, making it visible to anyone passing by. Multiple staff members and residents walked past the exposed information over a 37-minute period without addressing the privacy concern, and the Administrator later acknowledged the improper display of the chart.
A resident with dementia and an activated HCP had a missing denture that was reported to staff, but facility staff did not complete or process a grievance form as required by policy. The HCP submitted a grievance form after being given one by a nurse, but did not receive a timely response or resolution. Facility records lacked documentation of the missing denture or any follow-up, and staff interviews revealed confusion about the grievance process and notification. The administrator only became aware of the issue after receiving the completed grievance form from the HCP.
A resident admitted with neurogenic bladder and an indwelling urinary catheter did not receive a baseline or comprehensive care plan within 48 hours of admission, as required by facility policy. The resident was not provided with a written summary of the care plan, nor was a signature obtained to verify receipt, and the omission was confirmed by both the resident and consulting staff.
A resident with an indwelling urinary catheter and a diagnosis of neurogenic bladder did not have a comprehensive care plan developed to address catheter management, despite physician orders and a triggered MDS care area. The absence of this care plan was confirmed through observation, record review, and staff interview.
A resident with multiple risk factors for pressure ulcers, including impaired mobility and diabetes, was not consistently repositioned as required, and care plan interventions were not updated after a significant increase in risk. This resulted in the development of a deep tissue injury on the resident's heel, as confirmed by clinical documentation and staff interviews.
A nurse was observed disposing of dropped medications, Gabapentin and Sucralfate, into an uncovered trash bin on a medication cart instead of using the designated medication disposal area, contrary to facility policy. This occurred on a unit where most residents have Alzheimer's disease or dementia, increasing the risk of accidental access to medications. The DON confirmed the disposal method was improper and did not ensure resident safety.
During a medication pass, two nurses made three errors out of 28 opportunities, resulting in a medication error rate of 10.71%. Errors included administering the wrong probiotic formula to a resident and giving another resident the incorrect calcium supplement and a multivitamin instead of the prescribed PreserVision AREDS Tablet. The DON confirmed that nurses are expected to follow physician orders.
A resident who required substantial assistance with bathing was exposed to a violation of privacy and dignity when a CNA conducted a FaceTime call on a personal cell phone during the resident's shower. The resident, who was alert and oriented, observed and interacted with the caller, leading to feelings of embarrassment and humiliation. The CNA's actions were in direct violation of facility policies prohibiting personal cell phone use and ensuring resident privacy.
The facility failed to ensure the activities program was directed by a qualified professional. The AD, hired in July 2023, lacked the necessary qualifications and experience. After a leave of absence, it was confirmed in June 2024 that she was not qualified. The Regional AD and HR Director acknowledged the lack of a qualified AD since the previous AD's termination.
The facility failed to follow its food safety and sanitation policies, leading to potential foodborne illness risks. Observations revealed unlabeled and expired food items, disorganized and unclean kitchenettes, and equipment with buildup. The Food Service Director acknowledged these issues, indicating a lapse in policy adherence.
The facility failed to maintain a QAPI Committee with the required members, as the Infection Preventionist did not attend the last two quarterly meetings. The facility's policy requires the QAPI program to include a QAA Committee with specific interdisciplinary members, including the Infection Preventionist. Attendance sheets confirmed the absence, and the CNO acknowledged the expectation for the Infection Preventionist to be present.
The facility failed to document and address grievances raised by the Resident Council, violating residents' rights. The Activity Assistant did not take notes during meetings, and the Activity Director, despite knowing about ongoing complaints regarding food and laundry, did not ensure they were documented for resolution.
The facility failed to secure residents' personal and medical records, leaving them accessible in open areas. Observations showed the copy room and SDC's office doors were left open and unattended, with sensitive information visible and accessible. Interviews with the Administrator, CNO, and DON confirmed that these areas should have been secured to protect resident information.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their individual medical needs. This included a lack of care plans for residents with Foley catheters, psychotropic medications, anticoagulant medications, and complex medical conditions such as endocarditis and diabetes. Additionally, a resident at risk for elopement did not have a care plan addressing this risk, despite facility policy requirements.
The facility failed to meet professional standards for four residents, including not notifying a physician about a resident's high oxygen levels, lacking orders for blood sugar monitoring and psychotropic medication changes, not obtaining care orders for surgical drains, and incomplete skin assessments.
The facility failed to provide meaningful activities for residents on the West Unit, as observed by a surveyor. Despite a policy requiring activities to support residents' well-being, observations showed residents seated in the dining/dayroom with the television on and no other activities occurring. Interviews revealed that Activity Assistants were reassigned to CNA duties, leading to a lack of scheduled activities on the unit.
A facility failed to ensure nursing staff had the necessary competencies to care for a resident requiring IV antibiotics through a PICC line. The resident, admitted with endocarditis, did not have the external catheter length measured with each dressing change as ordered. Despite some education being provided, there was no system to verify that all nurses had the required training, leading to a deficiency in staff competency.
The facility failed to monitor adverse consequences of anticoagulant and anti-hypoglycemic medications for three residents. Two residents receiving anticoagulants were not monitored for side effects, and a resident with diabetes was not monitored for adverse consequences of hypoglycemic medications. Interviews with nursing staff confirmed the lack of monitoring orders, despite facility policies requiring such monitoring.
The facility failed to monitor adverse effects of psychotropic medications for several residents, despite policy requirements. Residents were prescribed medications like Escitalopram, Aripiprazole, and Xanax without documented monitoring for side effects. Interviews with staff confirmed the absence of necessary monitoring orders.
The facility failed to properly store medications, including leaving an IV medication unattended in a resident's room and not securing controlled substances in a locked compartment due to a broken lock. Loose pills and unlabeled inhalers were found in a medication cart, and a Tuberculin vial was not labeled with the opened date. Staff were aware of some issues but did not ensure compliance with storage protocols.
The facility failed to maintain accurate medical records and safeguard resident-identifiable information. A resident's care plan for a PICC line was inaccurately documented, another resident's record contained unrelated documents, and three residents lacked documented weekly skin assessments despite records indicating completion. These issues highlight deficiencies in documentation and confidentiality practices.
The facility failed to maintain effective infection control practices, as staff did not consistently use PPE or perform hand hygiene when required. A resident with a PICC line and another with multiple wounds were not provided care with the necessary precautions, and tables and residents' hands were not sanitized before meals. These deficiencies highlight significant lapses in adhering to Enhanced Barrier Precautions and standard hygiene protocols.
The facility failed to implement and maintain an effective training program for new and existing staff, as eight direct care staff members lacked documented evidence of completing required training. The facility's policy mandates training in areas such as effective communication, resident rights, and infection control, but none of the staff had completed all necessary training. The Staff Development Coordinator, new to the role, was still catching up on mandatory trainings, and no additional records were provided by the end of the survey.
The facility failed to provide mandatory training on effective communications for direct care staff, as required by their policy. Education records for two nurses and three CNAs lacked evidence of this training. The SDC, new to the role, confirmed the absence of documentation, and the CNO stated that such training should be completed upon hire and annually. No additional documentation was provided by the end of the survey.
The facility failed to ensure mandatory training on resident rights for direct care staff, as required by its policy. Interviews and record reviews revealed missing education records for two nurses and incomplete training documentation for three CNAs. The SDC, new to the role, acknowledged the absence of training evidence, and the CNO confirmed the training should occur upon hire and annually. No additional documentation was provided by the survey's end.
The facility failed to ensure mandatory training on the elements and goals of its QAPI program for direct care staff, as revealed through interviews and a review of staff education records. The Staff Development Coordinator, new to the role, acknowledged the absence of training documentation, and the Chief Nursing Officer confirmed that such training should occur upon hire and annually. Despite intentions to review records, no additional documentation was provided by the end of the survey.
The facility failed to provide mandatory training on infection control standards to direct care staff, as required by its policy. The Staff Development Coordinator, new to the role, could not provide evidence of such training for two nurses and two CNAs. The Chief Nursing Officer confirmed the training should occur upon hire and annually, but no additional records were provided by the survey's end.
The facility failed to provide mandatory training on compliance and ethics program standards to direct care staff, as required by their policy. A review of education records for several staff members revealed the absence of this training. The SDC, new to the role, acknowledged the lack of evidence for the training and the facility's reliance on paper records. The CNO confirmed the training should occur upon hire and annually, but no additional documentation was provided to the survey team.
The facility did not ensure mandatory behavioral health training for direct care staff, as required by policy. The Staff Development Coordinator, new to the role, acknowledged missing training records, and the Chief Nursing Officer confirmed the training should be completed upon hire and annually. No additional documentation was provided by the survey's end.
A resident prescribed enoxaparin for DVT prophylaxis post-hip surgery did not receive the medication as it was unavailable from the pharmacy. Nurse #3 documented the issue but failed to notify the Physician or Nurse Practitioner, as confirmed by Unit Manager #1.
The facility failed to create baseline care plans within 48 hours for two residents with complex medical needs, including diabetes and endocarditis with a PICC line. Despite having physician's orders for necessary treatments, the care plans were not developed, as confirmed by staff interviews.
A facility failed to document a recapitulation of a resident's stay at discharge, as required by policy. The resident, with multiple diagnoses, was discharged home without a completed discharge summary, including a physician's recapitulation note. Interviews revealed that the necessary documentation was not retrieved or written, and the Patient Care Referral Form was incomplete.
A resident with dementia and mobility issues experienced an unwitnessed fall with a head strike. A CNA moved the resident into a wheelchair before a nurse could assess them, contrary to the facility's Fall Reduction policy. The CNA left the resident standing in the bathroom, returned to find them on the floor, and moved them without notifying a nurse first. The DON and CNO confirmed the CNA should have notified a nurse immediately.
A facility failed to properly manage a resident's PICC line, leading to a deficiency. Nursing staff did not measure the external catheter length as ordered, and the insertion site was not visible for routine assessment due to an opaque pad. The resident, admitted with endocarditis, had a PICC line for antibiotic infusion. Documentation was lacking for 64 out of 81 shifts, and staff interviews revealed issues with dressing kits and incomplete hospital orders.
A resident using a CPAP machine did not have a physician's order for its use, which is required by the facility's policy. Despite the resident managing the CPAP themselves and staff assisting with its operation, no formal orders were documented. Interviews with staff, including the DON and CNO, confirmed awareness of the CPAP machine but acknowledged the absence of necessary orders.
A facility failed to ensure staff had the necessary skills to meet the behavioral health needs of a resident with dementia, anxiety disorder, major depressive disorder, and bipolar disorder. The resident exhibited behaviors such as calling out for attention and aggression, but staff lacked training in mental and psychosocial disorders. Observations and interviews confirmed the absence of adequate training, as noted by the facility's Staff Development Coordinator and Chief Nursing Officer.
A resident did not receive a prescribed anticoagulant medication due to a pharmacy delivery delay. The nurse failed to notify the physician or use the available emergency kit to administer the medication, resulting in a significant medication error.
The facility failed to provide mandatory training on abuse, neglect, and exploitation prevention for two nurses, as required by their policy. The Staff Development Coordinator, new to the role, could not provide documentation of the training, and the Chief Nursing Officer confirmed the training should be completed upon hire and annually.
A facility failed to accurately complete MDS assessments for a resident with a documented bipolar disorder diagnosis. Despite multiple medical evaluations confirming the diagnosis, the MDS assessments did not reflect this condition. Interviews with staff indicated an expectation for accuracy, yet the assessments did not meet this standard.
Failure to Notify Health Care Agent of Resident Condition Changes and New Orders
Penalty
Summary
Nursing staff failed to notify the Health Care Agent (HCA) of a resident with an activated Health Care Proxy about significant changes in the resident's condition and new physician orders. The facility's policy requires prompt notification of the resident's representative regarding changes in medical or mental condition, and documentation of such notifications in the medical record. However, the HCA was not informed of the resident's re-admission from the hospital, a new diet order, the presence of a blister on the right heel, or a vasovagal episode that resulted in new physician orders for lab work. The resident, who had diagnoses including dementia, bipolar disorder, diabetes, Parkinson's disease, hypertension, and hyperlipidemia, was re-admitted to the facility after hospitalization. Upon return, the resident required a dysphagia diet and had a fluid blister on the right heel, for which new treatment orders were obtained. Documentation showed that the diet requisition form was not completed until several days after re-admission, and there was no evidence that the HCA was notified of these changes. Additionally, the resident experienced an episode of unresponsiveness while with therapy, leading to further physician orders, but again, there was no documentation of HCA notification. Interviews with nursing staff and facility leadership confirmed that the HCA was not notified of the resident's condition changes or new orders, despite facility policy and expectations. The HCA only became aware of the incidents and changes after independently requesting and reviewing the resident's medical record. There was no documentation in the medical record to support that the required notifications were made to the HCA regarding the resident's new diet, treatment orders, or significant health events.
Failure to Provide Prescribed Dysphagia Diet After Hospital Readmission
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, diabetes, and Parkinson's disease, was readmitted to the facility with new dietary orders following a hospital stay. The hospital discharge summary specified that the resident required a dysphagia carbohydrate-consistent, soft/easy to chew diet with thin liquids due to aspiration risk. However, upon readmission, nursing staff failed to transcribe and communicate the new diet order, resulting in the resident receiving a regular texture diet for two days instead of the prescribed dysphagia diet. The facility's policies required that all diet orders be communicated to the dietary department and that documentation in the medical record be complete and accurate. Interviews and record reviews revealed that the nurse responsible for the resident's readmission overlooked the new diet order and instructed the kitchen to resume the previous regular diet. Another nurse later identified the discrepancy after reviewing the discharge paperwork and completed a diet requisition form for the correct diet, but this was not done until two days after readmission. The Food Service Director confirmed that the kitchen was not informed of the new diet order until the morning of the third day, resulting in the resident receiving the incorrect diet for two days. The Director of Nursing was unaware of the new diet order and acknowledged that two nurses should have reviewed all orders to prevent such errors.
Failure to Transcribe New Diet Order on Readmission
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident who was readmitted to the facility with new diet instructions following a hospital stay. The hospital discharge summary specified a new diet order for a Dysphagia Carbohydrate Consistent diet, 1600-2000 calories, soft/easy to chew with thin liquids. However, the resident's physician orders in the facility continued to reflect the previous Carbohydrate Consistent Diet with regular texture and thin liquids, and the new diet order was not transcribed into the resident's medical record. Nurse progress notes indicated that the kitchen was notified to resume the resident's previous diet, and interviews with nursing staff revealed that the new diet order from the hospital discharge summary was overlooked. The DON confirmed that it was expected for all nurses to review discharge paperwork to ensure all orders are accurately transcribed, but in this case, the new diet order was missed, resulting in incomplete and inaccurate documentation in the resident's medical record.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 2 2025, as required. Review of the Payroll Based Journal (PBJ) Staffing Report and CASPER Report 1705D indicated that no staffing data was submitted for the quarter, resulting in a one-star staffing rating. During an interview, the Director of Operations stated that a change in the corporate Human Resources position occurred at the time of the PBJ submission, and the facility was unaware that the required data had not been submitted. Attempts to submit the data after the deadline were unsuccessful, and the required information remained unreported.
Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, outbreak management, and sanitary medication administration practices. Observations revealed that a nurse prepared medications for a resident and, after dropping a pill onto the top of the medication cart, picked it up and administered it to the resident. The nurse stated that the cart had been cleaned at the start of her shift, but the DON confirmed that the top of the medication cart is not considered a clean surface and that the medication should have been discarded, as administering it posed an infection control concern. A review of the facility's infection surveillance documentation showed significant gaps and inconsistencies. Monthly infection line listings were incomplete, frequently missing critical information such as signs and symptoms of illness, dates of symptom onset, and culture results. Some laboratory results indicating the presence of significant pathogens were not included in the surveillance records. Additionally, the facility failed to track suspected infections that were not treated with antibiotics and did not maintain surveillance line listings for several months. The Infection Prevention Nurse acknowledged that the current system did not capture all necessary data, including symptoms, onset dates, and results from outside laboratories. The facility also failed to properly document and manage a COVID-19 outbreak. Although a significant number of residents tested positive for COVID-19 over a period of time, the facility did not maintain adequate records of outbreak investigation, contact tracing, or testing logs for staff and residents. The Infection Prevention Nurse was unable to provide documentation of who had been exposed, when testing occurred, or the results of staff testing. The only documentation available was a line listing of COVID-19 positive residents, which lacked information on symptoms and dates of onset.
Failure to Accurately Document Medication Administration and Advance Directives
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, resulting in discrepancies in documentation of medication administration and advance directives. For one resident with neurological conditions, there was a significant inconsistency between the number of times an opioid pain medication was documented as administered in the Electronic Medical Administration Record (EMAR) and the Narcotic Book. Specifically, the EMAR failed to record 17 out of 58 administrations, despite facility policy requiring documentation in both records. Nursing staff interviews confirmed that documentation was sometimes omitted due to being busy, and the Director of Nursing (DON) stated that her expectation was for staff to follow policy and ensure records matched. Additionally, the facility did not ensure that residents' advance directives, as indicated on their Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) forms, were accurately reflected in the medical record, physician's orders, and care plans. For one resident, the nurse practitioner's progress notes consistently listed the resident as Full Code, contradicting the MOLST, which specified Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) except for comfort. The nurse practitioner acknowledged the error, attributing it to auto-population in the documentation system. For two other residents, there were discrepancies between the MOLST forms and the physician's orders or care plans. In one case, the physician's orders and care plan listed the resident as Full Code and included interventions not permitted by the MOLST, such as resuscitation and artificial nutrition, while the MOLST specified DNR, DNI, and no artificial interventions. In another case, the physician's orders referenced an outdated MOLST and did not accurately reflect the current directives. The DON confirmed that all medical record information should be accurate and complete, and acknowledged the inconsistencies.
Failure to Implement Data-Driven QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) Committee developed, implemented, and maintained a comprehensive Quality Assurance Performance Improvement (QAPI) program. The QAPI policy required the use of data-driven analysis, benchmarking, and measurable goals for improvement, but these elements were not present in the facility's actual practices. The Administrator, who was responsible for QAPI, initiated a project to improve the grievance process but did not use data or benchmarks to establish a starting point or measure improvement, relying instead on subjective impressions of increased understanding and usage of the process. The Administrator also acknowledged missing a recent grievance, which was brought to attention by surveyors. The Director of Nursing (DON) was working on a project to improve completion of resident incident reports but did not know the baseline data or use metrics to track progress. The DON stated that the goal was 100% completion but had no data to determine the current status or to measure periodic improvement. Both the Administrator and DON admitted to lacking training on QAPI processes, including the use of systematic methods such as Plan-Do-Study-Act cycles, and were unaware of the tools available for managing and sustaining improvement. They described their approach as identifying a problem, providing education, and monitoring until a goal was met, without seeking feedback from line staff or ensuring sustainability of changes. The Director of Operations confirmed that the facility leadership was expected to use data-based evidence and metrics, including root cause analysis and measurable goals, to sustain improvements. However, based on the information provided, the Director of Operations acknowledged that the required processes for QAA and improvement projects were not in place as required by organizational policy. The deficiency was identified through interviews and review of facility practices, which did not align with the written QAPI policy.
Failure to Offer and Document COVID-19 Vaccination for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees' records contained evidence of being offered the 2024-2025 COVID-19 vaccination or documentation of their vaccination status. Specifically, four out of five new hires did not have documentation in their personnel files indicating that they had been offered the most recent COVID-19 vaccine, as recommended by the CDC. These employees, including nurses, an activity assistant, and a maintenance assistant, were actively working in the facility without this required documentation. Interviews with facility staff revealed that the Human Resources staff provided new hires with a list of required items, including proof of current COVID-19 vaccination, but did not verify whether the offer of the most recent vaccine was documented. The Infection Preventionist confirmed that the facility did not offer the COVID-19 vaccine or boosters to new staff upon hire, which accounted for the lack of documentation in the employee files. This failure to offer and document the COVID-19 vaccination for new hires was identified through personnel record review and staff interviews.
Failure to Maintain Privacy for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter was treated with respect and dignity, as required by facility policy and resident rights. Multiple observations revealed that the resident's urinary catheter drainage bag was consistently left uncovered and positioned in a way that made it visible from the doorway. These observations occurred while the resident was both awake and asleep, and the drainage bag was filled with clear/yellow urine each time. The facility's policy on promoting and maintaining resident dignity specifically requires maintaining resident privacy, which was not upheld in this case. The resident involved was cognitively intact and had a diagnosis of neurogenic bladder, requiring the use of a Foley catheter. Physician's orders documented the need for daily and as-needed catheter care, as well as regular monitoring and emptying of the drainage bag. Despite these orders and the facility's policy, staff did not ensure the catheter bag was covered or positioned to protect the resident's privacy. During an interview, a unit manager confirmed that the catheter bag should have been covered for privacy, acknowledging the lapse in maintaining the resident's dignity.
Resident Health Information Left Unsecured at Nurses' Station
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident information on one of its nursing units. A multi-page flip chart containing private health information, including residents' names, ADL schedules, shower lists, and special care needs, was left open and facing outward on top of the East unit nurses' station desk. This placement made the information visible to anyone passing by in the hallway. The flip chart remained in this position for a total of 37 minutes, during which time it was observed by the surveyor. During this period, various staff members—including the Maintenance director, Maintenance assistant, DON, Infection Preventionist, assigned nurse, Administrator, Laundry Aide, Regional Food Service Manager, Regional Director of Operations, and Rehab staff—walked past the exposed information 20 times without addressing the privacy concern. Additionally, two residents were observed passing by the nurses' station while the information was visible. The Administrator later confirmed that the flip chart was not supposed to be displayed in this manner and acknowledged the potential privacy violation.
Failure to Follow Grievance Policy for Missing Denture
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that the facility's grievance policy was followed when a resident's denture went missing. The resident, who had dementia and moderate cognitive impairment, was under hospice care and had an activated health care proxy (HCP). The HCP discovered the missing denture during a visit and was informed by staff that it had been missing for several days. The HCP was given a grievance form to complete, which she returned the following week, but did not receive a response from the facility. Review of facility records showed that no grievance form was completed by staff at the time the missing denture was first reported, and there was no documentation in the medical record regarding the missing denture or any efforts to resolve the issue. The facility's policy required staff to complete a grievance form for verbal complaints and to forward it to the Grievance Official for timely review and resolution, but this process was not followed in this case. Interviews with staff revealed uncertainty about whether a grievance form had been completed and a lack of clarity regarding who was notified in administration. The administrator confirmed that he was not aware of the missing denture until he received the completed grievance form from the HCP several days after the initial report. The failure to document and follow up on the grievance in accordance with facility policy resulted in a lack of prompt response and resolution for the resident and their representative.
Failure to Develop and Provide Baseline Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and provide a baseline or comprehensive care plan within 48 hours of admission for a resident with an indwelling urinary catheter. According to the facility's policy, a baseline care plan must be created within 48 hours of admission and include essential healthcare information such as physician orders, initial goals, and specific care instructions. The policy also requires that a written summary of the baseline care plan be provided to the resident or their representative, with a signature obtained to verify receipt and a copy placed in the medical record. In this case, the resident was admitted with a diagnosis of neurogenic bladder and had an indwelling urinary catheter, as documented in the admission assessment and physician's orders. Despite these requirements, review of the resident's medical record showed no evidence that a baseline or comprehensive care plan addressing the use of the indwelling urinary catheter was developed within the required timeframe. The resident confirmed during an interview that they were not provided with, nor asked to sign, a summary of a baseline care plan. Consulting staff also verified that the care plan for the urinary catheter was not completed as required. This deficiency was identified for one resident out of a sample of seventeen.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop, implement, and individualize a comprehensive care plan for a resident with an indwelling urinary catheter. Despite the facility's policy requiring a person-centered care plan to be developed within seven days of the comprehensive Minimum Data Set (MDS) assessment, and the resident's MDS assessment triggering a care area for urinary catheter, no care plan addressing the catheter was found in the resident's records. The resident, who was cognitively intact and had a diagnosis of uninhibited neurogenic bladder, had documented physician orders for Foley catheter use and care, as well as nursing assessments confirming the presence of the catheter. During the survey, the resident was observed with a urinary catheter in place, and a review of the care plans confirmed the absence of a care plan specific to the indwelling catheter. Consulting staff acknowledged that a care plan should have been developed for this triggered care area but was not. The deficiency was identified through observation, interview, and record review, demonstrating a failure to meet the facility's own policy and regulatory requirements for comprehensive care planning.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
A resident with a history of left femur fracture, diabetes mellitus, and dementia was admitted to the facility and identified as being at very high risk for developing pressure ulcers. Initial assessments and care plans documented the resident's impaired mobility, dependence on staff for bed mobility, and risk factors such as incontinence and comorbidities. Despite these documented risks, the resident did not receive consistent repositioning, as evidenced by gaps and omissions in the positioning documentation, with 42% of opportunities for repositioning either left blank, marked as not applicable, or coded as not done. The facility's policies required identification, assessment, and implementation of interventions for residents at risk of pressure ulcers, including regular skin inspections and care plan updates based on risk assessments. However, after a significant drop in the resident's Norton Scale score indicating very high risk, no new or revised interventions were implemented in the care plan. Interviews with staff revealed a lack of awareness regarding specific interventions such as heel offloading, and the resident did not receive an air mattress until after the development of a pressure injury. The resident subsequently developed a deep tissue injury on the left heel, which was confirmed by nursing notes and a wound physician's evaluation. The injury was attributed to pressure related to immobility, and the documentation indicated that the resident's skin was intact upon admission except for a surgical incision. The failure to consistently reposition the resident and to update care interventions in response to increased risk directly led to the development of the pressure injury.
Improper Disposal of Medications Creates Accident Hazard
Penalty
Summary
Staff failed to provide an environment free from accident hazards by not properly disposing of medications on the [NAME] Unit. Specifically, a nurse was observed dropping two medications, Gabapentin and Sucralfate, on the floor and then disposing of them in an uncovered trash bin attached to the medication cart, rather than following the facility's policy for secure medication disposal. The facility's policy requires that all unused, contaminated, or expired drugs be destroyed in a manner that renders them unfit for human consumption and disposed of in compliance with state and federal requirements. The [NAME] Unit houses a large population of residents with Alzheimer's disease and dementia, with 37 out of 39 residents having these diagnoses. The Director of Nursing confirmed that the nurse should not have disposed of the medications in the trash on the medication cart, but instead should have used the designated medication disposal area to ensure resident safety. The improper disposal of medications in an unsecured trash bin created a potential hazard for residents, particularly those with cognitive impairments.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 28 opportunities during a medication pass, resulting in a 10.71% error rate. Two out of three nurses observed made errors that affected two residents. Specifically, one nurse administered the incorrect probiotic formula to a resident, giving Acidophilus instead of the prescribed Saccharomyces boulardii, as per the physician's order. The nurse stated that Acidophilus was typically used as house stock and acknowledged not following the specific physician's order. Another nurse administered the incorrect formula of Calcium and provided a Multivitamin with Minerals instead of the prescribed PreserVision AREDS Tablet to a different resident. The nurse confirmed these errors during an interview. The Director of Nursing stated that the expectation is for nurses to administer medications according to physician orders. These actions resulted in a medication error rate exceeding the regulatory threshold.
Violation of Resident Privacy During Bathing Due to Staff FaceTime Call
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to honor a resident's right to privacy and dignity during a shower. The resident, who was alert, oriented, and required substantial assistance with bathing due to multiple sclerosis, reported that the CNA used her personal cell phone to conduct a FaceTime call while assisting with the shower. The resident described hearing the conversation on speaker and, at one point, seeing the face of the caller on the phone's screen after it fell from the CNA's pocket. The resident made eye contact with the caller and engaged in brief conversation, which left the resident feeling shocked, embarrassed, and humiliated, especially given the exposure while naked and being bathed. The facility's policies explicitly prohibited personal cell phone use on nursing units and guaranteed residents' rights to personal privacy. Despite these policies, the CNA admitted during an internal interview to being on a FaceTime call during the resident's shower, although she later gave a conflicting account to the surveyor. The incident was corroborated by the resident's consistent statements and the CNA's initial admission, as well as written statements from facility staff who participated in the internal investigation.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Activity Director (AD) was hired in July 2023 after the former AD left, but she took a leave of absence shortly after starting. Upon her return in June 2024, it was found that her personnel file did not indicate she was a qualified therapeutic recreation specialist or an activities professional with the required experience. Interviews with the AD and the Regional Activity Director confirmed that the AD was not qualified to direct the activity program. The Human Resource Director also acknowledged that the facility had been without a qualified AD since the termination of the former AD in July 2023.
Food Safety and Sanitation Deficiencies in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to its policies and professional standards for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. The surveyor observed that the facility did not properly label and date food products, nor did it maintain clean and safe equipment in the nourishment kitchenettes. Specifically, the facility's policy required that all open food items be labeled with the resident's name, date of birth, room number, and expiration date, but this was not consistently followed. Additionally, the facility's policy mandated regular cleaning and organization of kitchenettes, which was not adequately performed. During the survey, the [NAME] Unit kitchenette was found to have a sink faucet and handheld spray nozzle with brown buildup, disorganized cabinets and drawers, and a freezer with ice buildup. There were also expired thickened beverage packets and an unlabeled, undated bottle of nutritional supplement in the refrigerator. Similarly, the East Unit kitchenette had a soiled microwave, disorganized cabinets and drawers with spilled sugar, and a refrigerator with red liquid drips. An opened, undated container of prune juice and unlabeled ice cream were also found. The Food Service Director (FSD) acknowledged these deficiencies during an interview and observation with the surveyor. The FSD confirmed that the kitchen staff were responsible for stocking, monitoring, and cleaning the unit kitchenettes, but admitted to being unaware of the prune juice's consumption range and the expired thickened beverage packets. The FSD agreed that the observed conditions did not meet the facility's standards for cleanliness and food safety, indicating a lapse in adherence to established policies.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members present at their meetings. Specifically, the Infection Preventionist did not attend the last two quarterly QAPI meetings. The facility's policy mandates that the QAPI program includes a Quality Assessment and Assurance (QAA) Committee, which must be interdisciplinary and include the Director of Nursing Services, the Medical Director or designee, at least three other staff members, and the Infection Preventionist. Review of the QAPI Attendance Sheets for meetings held on specific dates showed that the Infection Preventionist's designated signature space was blank, indicating their absence. During an interview, the Chief Nursing Officer confirmed that the Infection Preventionist had not signed in for the meetings, acknowledging that the expectation was for their presence at the QAPI meetings.
Failure to Document and Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances and concerns raised by the Resident Council were properly documented and addressed in a timely manner. The facility's policy required that the Activity Director or a designated liaison serve as a communication link between the Resident Council and the facility's administration, and that concerns and recommendations from the Council be acted upon and communicated back to the Council. However, during a surveyor's review of the Resident Council Minutes from March to May 2024, it was found that the minutes did not accurately reflect the meetings. The Resident Council President reported that recurring issues with food quality and laundry services were discussed at every meeting, yet no follow-up actions were taken by the facility. The Activity Assistant, who ran the meetings in the absence of the Activity Director, admitted to not taking notes or documenting the discussions. The Activity Director, upon returning, acknowledged the ongoing complaints about food and laundry but did not ensure they were documented on grievance forms for resolution. This lack of documentation and follow-up led to the residents' grievances not being addressed, violating the residents' rights to have their concerns acted upon by the facility.
Failure to Secure Resident Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records. Observations revealed that the door to the copy room on the main hallway was left open and unattended, with boxes labeled as medical records visible from the hallway. These boxes contained sensitive information such as hospital discharge summaries and resident diagnoses. Additionally, physician notes with medical diagnoses and resident face sheets were left on the fax machine, accessible to anyone passing by. Interviews with the Administrator and Chief Nursing Officer (CNO) confirmed that the door should have been locked to protect resident information. Further observations showed that the Staff Development Coordinator's (SDC) office door was also left wide open with no staff present. Inside, there were large piles of residents' physician's orders and binders containing private health information, including residents' names, dates of birth, allergies, diagnoses, diet orders, treatment orders, and medication orders. The Director of Nursing (DON) acknowledged that the SDC's office door should be closed at all times when unattended to secure resident records. Despite this, repeated observations found the door open and unattended, with sensitive information accessible to anyone.
Deficiencies in Comprehensive Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for nine residents, leading to deficiencies in addressing their individual medical needs. For instance, a resident with an indwelling Foley catheter did not have a care plan for monitoring urine color, consistency, and odor, despite physician orders indicating the necessity for such monitoring. Additionally, this resident was on multiple psychotropic medications without a corresponding care plan, which was acknowledged as a requirement by the Unit Manager and the Director of Nursing (DON). Another resident receiving anticoagulant medication did not have a care plan in place, despite receiving the medication as ordered. This oversight was confirmed by a nurse and the DON, who both stated that a care plan should have been developed and implemented. Similarly, a resident on antidepressant medication had a care plan that was not fully implemented, as the facility failed to monitor potential side effects of the medication, which was a stipulated intervention in the care plan. Further deficiencies were noted in the lack of comprehensive care plans for residents with complex medical conditions such as endocarditis requiring PICC line antibiotic therapy, diabetes mellitus requiring insulin and other medications, and a cardiac pacemaker. Additionally, a resident assessed as a moderate risk for elopement did not have a care plan addressing this risk, despite the facility's policy requiring such plans for residents with elopement risks. These failures were identified through interviews with nursing staff and a review of medical records, highlighting a systemic issue in care plan development and implementation.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice for four residents, leading to deficiencies in care. For one resident with COPD, the facility did not notify the physician when the resident's oxygen saturation levels consistently exceeded the prescribed range of 88-92%. Despite the resident receiving oxygen therapy as ordered, the oxygen saturation levels were often recorded above the specified range, and the nursing staff did not inform the physician to reassess the treatment plan. Another resident with diabetes mellitus did not have physician's orders for fingerstick blood sugars (FSBS) to implement sliding scale insulin administration. The resident's blood glucose levels were monitored without an official order, and there were no documented interventions for potential hypoglycemia. Additionally, a psychotropic medication order was incorrectly documented, leading to the resident not receiving the medication as intended for ten days, without notifying the physician. A third resident with a rectal abscess had [NAME] drains placed but lacked orders for their care and maintenance. The hospital discharge summary did not provide instructions for the drains, and the facility did not obtain necessary orders to monitor for placement and signs of infection. Lastly, a resident with a wound infection did not have comprehensive weekly skin assessments documented, as required by the facility's policy. The assessments failed to include detailed descriptions and measurements of the wounds, which were necessary for ongoing treatment evaluation.
Failure to Provide Engaging Activities for Residents
Penalty
Summary
The facility failed to provide a meaningful and engaging activity program for residents on the West Unit, as observed by the surveyor. The facility's policy on activities, last revised on 3/4/24, mandates that activities should be designed to meet the interests of each resident and support their physical, mental, and psychosocial well-being. However, during the surveyor's observations on 6/24/24, 6/25/24, and 6/26/24, it was noted that residents were seated in the dining/dayroom area with the television on at a low volume, and no other activities were taking place. Residents had no materials for self-directed activities, and no staff were present to facilitate activities. Interviews with staff revealed that the facility had stopped scheduling activities on the West Unit because Activity Assistants were being reassigned to work as CNAs. Activity Assistant #1, who is also a CNA, mentioned that she usually sets up activities in the morning but then assists with activities off the unit. The Activity Director confirmed that due to staffing issues, Activity Assistants were no longer sent to the West Unit, resulting in a lack of organized activities for the residents there.
Deficiency in Nursing Staff Competency for IV/PICC Line Care
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the appropriate competencies and skills to care for a resident who required intravenous (IV) administration of antibiotics through a Peripherally Inserted Central Catheter (PICC). This deficiency was identified for one resident out of a sample of 19. The facility did not ensure that nine nursing staff, including the Director of Nursing, had demonstrated the necessary competencies to care for residents with specialized needs, such as IV/PICC line care and treatment. The resident in question was admitted with a diagnosis of endocarditis and had a PICC line for antibiotic infusion. The facility's policy required that the external catheter length be measured with each dressing change, as ordered by the physician. However, the medical record review revealed that the external catheter length was not measured with each dressing change, as there was no documentation to indicate this had been done since the initial dressing change upon admission. Interviews with the Staff Development Coordinator revealed that there was no system in place to ensure that all nurses providing IV care had the required training and competencies. Although education on PICC line and Midline care was provided to some nurses, competency checklists were not completed for any nursing staff. This lack of documentation and oversight contributed to the deficiency in ensuring appropriate competencies for nursing staff.
Failure to Monitor Adverse Consequences of Medications
Penalty
Summary
The facility failed to monitor adverse consequences of anticoagulant and anti-hypoglycemic medications for three residents. For two residents, the facility did not monitor for side effects of anticoagulant medications. One resident, admitted with hypertension and alcohol abuse, received Enoxaparin Sodium but was not monitored for adverse consequences. Another resident, admitted with atrial fibrillation, received Apixaban without monitoring for side effects. Interviews with nursing staff confirmed the lack of monitoring orders for these residents. Additionally, the facility did not monitor for adverse consequences of hypoglycemic medications for a resident with diabetes mellitus. This resident was prescribed multiple medications to manage blood sugar levels, including Farxiga, Glipizide, Humalog, and Insulin Glargine. Despite receiving these medications as ordered, there was no documentation of monitoring for adverse consequences in the resident's medical records. Interviews with the Chief Nursing Officer confirmed the expectation for monitoring, which was not met. The facility's policies on managing high-risk medications and hypoglycemia management were not followed, as evidenced by the lack of monitoring for adverse consequences in the residents' care plans and medical records. The Director of Nursing and Chief Nursing Officer acknowledged the deficiency in monitoring practices during interviews, highlighting a systemic issue in ensuring the safety and efficacy of medication administration.
Failure to Monitor Psychotropic Medication Adverse Effects
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, affecting five residents. The facility did not monitor these medications for adverse consequences, which is a requirement according to their policy. The policy states that residents should not be given psychotropic drugs unless necessary for a specific condition, and the response to these medications, including any adverse effects, should be documented in the medical record. Resident #55, admitted with anxiety, obsessive-compulsive disorder, and depression, was prescribed multiple psychotropic medications, including Escitalopram, Aripiprazole, Remeron, and Xanax. However, there was no documentation in the medical record indicating that Resident #55 was monitored for potential adverse consequences of these medications. Interviews with the Unit Manager and the Director of Nursing confirmed that there should have been orders to monitor for side effects, but none were present. Similarly, Resident #78, diagnosed with major depressive disorder, was receiving Citalopram and Sertraline. The care plan included goals and interventions for monitoring adverse reactions, but the medical record lacked documentation of such monitoring. Interviews with nursing staff and the DON revealed that monitoring orders were missing. This pattern of inadequate monitoring was also observed in Residents #30, #10, and #32, who were on various psychotropic medications without documented monitoring for adverse effects, as confirmed by staff interviews.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, resulting in several deficiencies. An IV medication was left unattended in a resident's room, contrary to the facility's policy that requires such medications to be stored in the medication room or cart. This incident occurred when a nurse left the medication to search for the resident, acknowledging it was not her usual practice. Additionally, the facility's medication cart was found to contain multiple loose pills, unlabeled inhaler devices, and controlled substances not stored in a separately locked compartment, as required by policy. The lock on the compartment had been broken for weeks, and although the pharmacy had been contacted for repair, there was no information on when it would be fixed. Further deficiencies were observed in the medication room, where a multi-dose vial of Tuberculin was not labeled with the opened date and expiration date, as per the manufacturer's guidelines. The vial should have been discarded after 30 days of being opened. The staff, including the DON and CNO, were aware of some of these issues, such as the broken lock, but failed to ensure compliance with the storage requirements. These lapses in medication management highlight significant deviations from the facility's policies and accepted professional principles.
Deficiencies in Medical Record Accuracy and Confidentiality
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in documentation and safeguarding of resident-identifiable information. For one resident, the facility did not accurately document the recommendations from a consultant infectious disease physician regarding the plan of care for a peripherally inserted central catheter (PICC). The resident was receiving intravenous antibiotics for endocarditis, and the medical record inaccurately indicated the removal date of the PICC line and the start of oral antibiotics, which was not in line with the physician's recommendations. Another resident's electronic medical record contained scanned documents that were not related to them, including psychiatric consultant progress notes for other residents. This error was identified during a review of the electronic medical record, indicating a failure to ensure that documents were uploaded into the correct resident's medical record, thus compromising the confidentiality and accuracy of the resident's medical information. Additionally, the facility failed to document weekly comprehensive skin assessments for three residents as per physician orders. Although the treatment administration records indicated that weekly skin checks were completed, the corresponding assessment forms were missing from the medical records. This discrepancy suggests that the skin assessments were either not performed or not properly documented, which is a deviation from the facility's policy requiring thorough documentation of skin assessments.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies related to the use of personal protective equipment (PPE) and hygiene practices. For Resident #72, staff did not adhere to Enhanced Barrier Precautions (EBP) and Contact Precautions, as a Certified Nursing Assistant (CNA) was observed handling bed linen without wearing a gown, despite the resident's condition requiring such precautions. This oversight was compounded by a lack of awareness among staff regarding the resident's precautionary status. Resident #74, who had a Peripherally Inserted Central Catheter (PICC) line, was also subject to inadequate infection control measures. A nurse was observed failing to perform hand hygiene and not wearing a gown while handling the PICC line and assisting the resident, contrary to the requirements of EBP. This lapse in protocol was attributed to the nurse's lack of knowledge about the necessity of wearing a gown during such procedures. Additional deficiencies were noted with Residents #17, #6, and #55, where staff failed to wear appropriate PPE during high-contact care activities. For instance, a nurse used ungloved hands to clean blood from Resident #17's face, and staff did not wear gowns while providing perineal care to Resident #6 or transferring Resident #55. Furthermore, the facility did not ensure tables were cleaned or residents' hands were sanitized before meals, as observed in the dining area, indicating a broader issue with infection control practices.
Failure to Implement and Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for both new and existing staff members, as evidenced by the lack of documented training for eight direct care staff members. The facility's policy, revised on 3/4/24, mandates that training requirements be met before staff and volunteers independently provide services to residents, annually, and as necessary based on the facility assessment. The training content should include effective communication, resident rights, QAPI, infection prevention and control, compliance and ethics, behavioral health, dementia management, abuse prevention, and safety procedures. However, upon review, it was found that none of the eight direct care staff members had completed all the required training, with some having no records of training at all. Interviews conducted during the survey revealed that the Staff Development Coordinator (SDC), who had been in the role for only three months, was still trying to catch up on mandatory trainings. The SDC confirmed that all education files and records had been provided to the survey team and acknowledged the absence of evidence for mandatory trainings. The Chief Nursing Officer (CNO) also stated that mandatory trainings should be completed upon hire and annually, as per facility policy. Despite these acknowledgments, no additional training records were provided by the end of the survey, indicating a systemic failure in maintaining an effective training program.
Deficiency in Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that training on effective communications was included as mandatory training for direct care staff. This deficiency was identified during a review of staff education records for five direct care staff members, including two nurses and three certified nursing assistants (CNAs). The facility's policy on training requirements, revised on March 4, 2024, mandates that training on effective communication should be completed prior to staff independently providing services to residents, annually, and as necessary based on the facility assessment. However, the facility was unable to provide the surveyor with education folders for the two nurses, and the records for the three CNAs did not include the required training on effective communications. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team and confirmed that the facility did not utilize electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for effective communication training in the employee records. The Chief Nursing Officer (CNO) also stated that the mandatory training for effective communication should be completed upon hire and annually. Despite these acknowledgments, the survey team did not receive any additional education or training documentation by the end of the survey.
Deficiency in Mandatory Training on Resident Rights
Penalty
Summary
The facility failed to ensure that training on resident rights was included as mandatory training for direct care staff. This deficiency was identified through interviews and a review of staff education records for five direct care staff members, including two nurses and three certified nursing assistants (CNAs). The facility's policy, revised on 3/4/24, mandates that training on resident rights and facility responsibilities should be completed prior to staff independently providing services to residents, annually, and as necessary. However, the facility was unable to provide the surveyor with education records for two nurses, and the records for the three CNAs did not include the mandatory training on resident rights. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team and confirmed that the facility did not use electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for training on resident rights. The Chief Nursing Officer (CNO) stated that the mandatory training should be completed upon hire and annually. Despite the SDC's efforts to locate additional records, no further documentation was provided to the survey team by the end of the survey.
Failure to Provide Mandatory QAPI Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that training on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program was included as mandatory training for direct care staff. This deficiency was identified through interviews and a review of staff education records for five direct care staff members, including two nurses and three certified nursing assistants (CNAs). The facility's policy, revised on 3/4/24, mandates that training requirements should be met before staff and volunteers independently provide services to residents, annually, and as necessary based on the facility assessment. However, the facility was unable to provide the surveyor with an education folder or packet for the two nurses, and the education records for the three CNAs did not include the mandatory QAPI training. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team and confirmed that the facility did not utilize electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for the QAPI training in the employee records. The Chief Nursing Officer (CNO) stated that the mandatory QAPI training should be completed upon hire and then annually. Despite the SDC's intention to review records again, no additional education or training documentation was provided to the survey team by the end of the survey.
Deficiency in Mandatory Infection Control Training
Penalty
Summary
The facility failed to ensure that mandatory training on written standards, policies, and procedures for the infection prevention and control program was provided to direct care staff. This deficiency was identified during a review of staff education records for four direct care staff members, including two nurses and two certified nursing assistants (CNAs). The facility's policy, revised on 3/4/24, mandates that training requirements should be met before staff and volunteers independently provide services to residents, annually, and as necessary based on the facility assessment. However, the facility was unable to provide evidence of such training for Nurses #1 and #9, and the records for CNAs #7 and #10 did not include the required training. Interviews conducted during the survey revealed that the Staff Development Coordinator (SDC), who had been in the role for three months, acknowledged the absence of evidence for the mandatory training. The SDC mentioned that all education was completed on paper, and the facility did not use electronic training programs. Despite reviewing the employee records with the surveyor, the SDC could not provide documentation of the training. The Chief Nursing Officer (CNO) confirmed that the training should be completed upon hire and annually. By the end of the survey, no additional education or training records were provided to the survey team.
Deficiency in Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that training on written standards, policies, and procedures for the compliance and ethics program was included as mandatory training for direct care staff. This deficiency was identified during a review of staff education records for eight direct care staff members, including nurses and certified nursing assistants. The facility's policy, revised on 3/4/24, mandates that training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. However, the education records for several staff members, including Nurse #8, CNA #1, CNA #7, CNA #4, CNA #11, and CNA #10, did not include the required training on the compliance and ethics program. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team, and confirmed that the facility did not utilize electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for the required training in the employee records. The Chief Nursing Officer (CNO) also stated that the mandatory training should be completed upon hire and annually. Despite the SDC's efforts to locate additional records, the survey team did not receive any further documentation by the end of the survey.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that mandatory training on behavioral health was provided to direct care staff, as required by their policy. The policy, revised on 3/4/24, mandates that training requirements, including behavioral health, should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. However, upon review of the staff education records for eight direct care staff members, including nurses and CNAs, it was found that none had completed the mandatory training on behavioral health. Additionally, the facility was unable to provide the surveyor with an education folder for two of the nurses. Interviews conducted during the survey revealed that the Staff Development Coordinator (SDC), who had been in the role for three months, acknowledged the absence of evidence for the behavioral health training in the employee records. The SDC mentioned that all education was completed on paper, and the facility did not use electronic training programs. The Chief Nursing Officer (CNO) confirmed that the mandatory training on behavioral health should be completed upon hire and then annually. Despite the SDC's efforts to locate the missing records, no additional education or training documentation was provided to the survey team by the end of the survey.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of a change in treatment for a resident who was prescribed an anticoagulant medication, enoxaparin, following surgery for a hip fracture. The resident, who had a history of dementia, was admitted to the hospital after a fall and underwent surgery for the fracture. Upon discharge, the resident was prescribed enoxaparin for Deep Vein Thrombosis (DVT) prophylaxis. However, the medication was not available from the pharmacy and was not administered as ordered on the specified date. Nurse #3 documented the unavailability of the medication in the Medication Administration Record (MAR) using a code and a note indicating 'n/a' for not available, but failed to notify the Physician or Nurse Practitioner about the missed dose. This oversight was confirmed during interviews with Nurse #3 and Unit Manager #1, who acknowledged that the Physician or Nurse Practitioner should have been informed about the medication not being administered as ordered.
Failure to Develop Timely Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline or comprehensive care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. For one resident with diabetes mellitus, the facility did not create a care plan addressing the resident's diagnosis, treatment, and monitoring needs, despite having physician's orders for multiple anti-diabetic medications. This oversight was confirmed during an interview with a unit manager who acknowledged that a care plan should have been developed. Similarly, another resident admitted with endocarditis and a PICC line for intravenous antibiotic therapy did not have a baseline or comprehensive care plan developed within the required timeframe. The resident's medical record included physician's orders for antibiotic administration and PICC line maintenance, but these were not incorporated into a care plan. A nurse confirmed the absence of a care plan for the resident's specific medical needs during an interview, acknowledging that it should have been created.
Failure to Document Discharge Recapitulation
Penalty
Summary
The facility failed to document a recapitulation of a resident's stay at the time of discharge, which is a requirement according to their policy on anticipated transfers or discharges. The policy mandates that a member of the interdisciplinary team completes relevant sections of the Discharge Summary, including a recap of the resident's stay, a final summary of the resident's status, medication reconciliation, and a post-discharge plan of care. However, for one resident, the medical record did not include a physician's recapitulation of stay, and the sections for physician's orders and signature on the Patient Care Referral Form were incomplete. The resident in question had multiple diagnoses, including metabolic encephalopathy, urinary tract infection, hypertension, diabetes mellitus, chronic kidney disease stage three, muscle weakness, a displaced bimalleolar fracture, hyperlipidemia, and anxiety disorder. Despite being discharged home with services, the necessary documentation was not completed. Interviews with the Director of Nursing and the Administrator revealed that the recapitulation note was not retrieved or written, and the Social Worker confirmed the absence of a completed discharge summary for the resident.
Failure to Follow Fall Protocol for Resident with Unwitnessed Fall
Penalty
Summary
The facility failed to ensure safe nursing care for a resident who experienced an unwitnessed fall with a head strike. The incident involved a Certified Nursing Assistant (CNA) who moved the resident off the floor and into a wheelchair before a nurse could assess the resident. According to the facility's Fall Reduction policy, a physical assessment should be conducted immediately after a fall, especially if it is unwitnessed or involves a head injury. However, the CNA did not follow this protocol and instead moved the resident, potentially compromising the resident's safety. The resident, who had been admitted with diagnoses including dementia and mobility issues, required maximum assistance for various activities. On the day of the incident, the CNA left the resident standing in the bathroom to dispose of dirty laundry and returned to find the resident on the floor. Despite the facility's policy, the CNA assisted the resident into a wheelchair and brought them to the common area before notifying a nurse. This action was confirmed by statements from the CNA and the nurse involved, as well as interviews with other staff members. The Director of Nursing and Chief Nursing Officer acknowledged that the CNA should have notified a nurse immediately to assess the resident.
Deficiency in PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The nursing staff did not measure the external length of the PICC line catheter as ordered by the physician, which is crucial to ensure that the catheter had not migrated out of place. Additionally, the insertion site was not visible for routine assessment by licensed nurses, as it was covered by an opaque pad, preventing proper visualization and assessment for signs of infection. The resident involved was admitted to the facility with a diagnosis of endocarditis and had a PICC line for the infusion of antibiotic medication. The medical record review indicated that the PICC line dressing was changed multiple times, but the external catheter length was not measured with each dressing change as required. Furthermore, the medical record lacked documentation of the insertion site assessment for 64 out of 81 shifts, indicating a significant lapse in monitoring and documentation practices. Interviews with facility staff, including a unit manager and staff development coordinator, revealed that the standard dressing kit provided by the pharmacy included an opaque pad, which hindered the visibility of the insertion site. The staff acknowledged the importance of visualizing the site for signs of redness or swelling and admitted that the insertion site should be assessed and documented every shift. The staff development coordinator also noted that orders from the hospital were often incomplete and required clarification, which contributed to the oversight in specifying the type of dressings to be used and ensuring site visibility for assessment.
Failure to Obtain Physician's Order for CPAP Machine
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards of practice for a resident who used a continuous positive airway pressure (CPAP) machine. The resident, who was cognitively intact, brought their CPAP machine from home and managed it themselves. However, the facility did not obtain a physician's order for the CPAP machine, which is required to include settings such as CPAP pressure, oxygen flow if needed, and a cleaning schedule. The facility's policy mandates that licensed staff are responsible for the operation of the CPAP machine, and physician orders should be checked to ensure proper settings and documentation. Interviews with staff, including a unit manager, nurses, and the Director of Nursing (DON) and Chief Nursing Officer (CNO), revealed that they were aware of the resident's CPAP machine but acknowledged the absence of a physician's order. The resident mentioned that nurses assisted with filling the water reservoir and turning on the machine, yet no formal orders were documented in the resident's medical record. Observations confirmed the resident used the CPAP machine, but the lack of a physician's order for its use was a clear deficiency in the facility's adherence to its own policy and professional standards.
Deficiency in Staff Training for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff members had the necessary skills and competencies to meet the behavioral health needs of a resident with multiple psychiatric and cognitive impairments. The resident, who was admitted with diagnoses including dementia, anxiety disorder, major depressive disorder, and bipolar disorder, exhibited behaviors such as calling out for attention, anxiousness, and aggression. The care plans for the resident included interventions to manage these behaviors, but the staff lacked the appropriate training to effectively implement these interventions. Observations and interviews revealed that staff members, including a CNA and a nurse, did not receive adequate training in caring for residents with mental and psychosocial disorders. The facility's Staff Development Coordinator confirmed that all education records were provided, and the Chief Nursing Officer stated that mandatory training should be completed upon hire and annually. However, the education documents did not show evidence of such training for the involved staff members, leading to the deficiency in meeting the resident's behavioral health needs.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an anticoagulant medication was not administered according to the physician's orders. The resident, who had a history of dementia, was admitted to the hospital for a hip fracture and underwent surgery. Upon discharge, the resident was prescribed enoxaparin for DVT prophylaxis, to be administered daily. However, on the first day of administration, the medication was not given because it had not been delivered by the pharmacy. Nurse #3 documented the medication as not available but failed to notify the physician or nurse practitioner about the unavailability and the missed dose. Additionally, the nurse did not utilize the emergency kit, which contained the required medication, to administer the dose. The unit manager confirmed that the nurse should have notified the physician and accessed the emergency kit to ensure the medication was administered as ordered.
Lack of Mandatory Training on Abuse Prevention
Penalty
Summary
The facility failed to ensure that mandatory training on abuse, neglect, and exploitation prevention was provided to all direct care staff, as evidenced by the lack of training records for two nurses, Nurse #1 and Nurse #9, out of eight employees reviewed. The facility's policy, revised on 3/4/24, mandates that such training should be completed prior to staff independently providing services to residents, annually, and as necessary based on the facility assessment. However, during the survey, the facility was unable to provide documentation of this training for the two nurses in question. Interviews conducted during the survey revealed that the Staff Development Coordinator (SDC), who had been in the role for three months, acknowledged the absence of evidence for the required training and stated that all education was completed on paper, with no electronic training programs in use. The Chief Nursing Officer (CNO) confirmed that the training should be completed upon hire and annually. Despite the SDC's efforts to locate the missing records, no additional documentation was provided to the survey team by the end of the survey.
Inaccurate MDS Assessment for Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the diagnosis of bipolar disorder for one resident in a sample of 19. The resident, admitted in January 2024, had a documented history of bipolar disorder as noted in various medical evaluations and notes, including an Initial Psych Evaluation and Chronic Care Management note. Despite this, the MDS assessments for the resident, specifically the Admission, Quarterly, and Discharge assessments, did not include the bipolar disorder diagnosis in Section I: Active Diagnoses. Interviews with facility staff, including MDS Nurse #1 and the Chief Nursing Officer (CNO), revealed that it was their expectation that MDS assessments be completed accurately. However, the assessments failed to reflect the resident's bipolar disorder diagnosis, indicating a lapse in the facility's adherence to its policy on MDS 3.0 Completion, which requires comprehensive and accurate assessments to identify care needs and develop an interdisciplinary care plan.
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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