D'youville Senior Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 981 Varnum Avenue, Lowell, Massachusetts 01854
- CMS Provider Number
- 225515
- Inspections on file
- 29
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at D'youville Senior Care during CMS and state inspections, most recent first.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician’s orders was found unresponsive without respirations or pulse. The assigned nurse, without checking the chart or MOLST, told a unit manager that the resident was a full code, and another nurse relied on this information without verification. Based on this incorrect verbal report, the unit manager initiated CPR, including chest compressions and use of an AED, and multiple rounds of compressions were performed. Only after a nurse later reviewed the MOLST and confirmed the DNR/DNI status was CPR stopped, revealing that the resident’s right to self-determination and advance directives had not been honored.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician orders was found unresponsive by the assigned nurse during medication pass. The nurse, relying on another nurse’s statement and without checking the chart or MOLST, reported to the unit manager that the resident was a full code. A second nurse also accepted this information without verification, and the unit manager initiated CPR, including chest compressions and AED use. While CPR was underway, the MOLST was reviewed, revealing the resident’s DNR/DNI status, and resuscitation was then stopped. The DON later acknowledged that staff failed to verify the code status before initiating CPR.
A resident with traumatic brain injury, morbid obesity, major depressive disorder, moderate cognitive impairment, and significant ADL dependence was subjected to repeated verbally demeaning comments by a hospice aide during care, including being called a pig, fat, and threatened with being taken to a slaughterhouse or butcher shop after the resident used racial slurs toward the aide. CNAs present during these incidents reported feeling uncomfortable but did not intervene, redirect, or promptly report the aide’s conduct, despite facility policy requiring all personnel to protect and promote resident rights to dignity, respect, and recognition of individuality. Leadership later confirmed staff accounts of the aide’s insulting remarks and acknowledged that such communication toward a resident was unacceptable.
Staff failed to follow the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. In one case, a resident with dementia and other conditions cried out that he/she had been slapped during a transfer, and a nurse heard a slap and the resident’s statement but allowed the CNAs to continue care and delayed reporting the allegation to a supervisor. In another case, a resident with TBI, morbid obesity, and major depressive disorder was allegedly subjected to repeated verbal abuse by a hospice aide, including being called a pig and fat, while CNAs who witnessed these incidents did not report them at the time and one initially denied knowledge when questioned, only disclosing the abuse later during an investigation.
A resident with traumatic brain injury, morbid obesity, and major depressive disorder alleged that a hospice aide repeatedly made demeaning, verbally abusive comments, including calling the resident a pig and fat, and comparing the resident to an animal, while CNAs present did not intervene or promptly report the incidents. Two CNAs later acknowledged witnessing these exchanges, in which the hospice aide responded to the resident’s racial slurs with insulting remarks about the resident’s weight, but both failed to immediately report the alleged abuse and one initially denied any knowledge when questioned by the ADON. Despite a facility policy requiring immediate reporting of alleged abuse so that notifications to state agencies occur within two hours, the facility did not submit its report of the verbal abuse allegation until several days after at least one of the incidents.
Two residents with diabetes did not receive proper foot care as ordered, including missed treatments, lack of documentation, and absence of required physician orders. Nursing staff either failed to provide care, did not document omissions, or delegated tasks without appropriate oversight.
Surveyors found that medications, including unopened insulin vials, were improperly stored outside the refrigerator, treatment supplies were mixed with oral meds, and medication carts were unclean with spills. Open insulin vials and an Albuterol inhaler lacked resident identifiers and were not in original packaging. Staff interviews confirmed these practices did not follow facility policy for medication storage, labeling, and cleanliness.
Surveyors found that the facility did not consistently label and date food items in the main kitchen and unit kitchenettes, failed to discard decomposed produce, improperly stored food on the floor and under potential contamination sources, and did not follow procedures for handling dented cans. Staff interviews confirmed that these actions were not in line with facility policy or professional standards.
The facility failed to ensure accurate documentation in the medical records for three residents. One resident with severe cognitive impairment and high risk for pressure ulcers was repeatedly documented as wearing a physician-ordered Prevalon boot, though observations showed the boot was not in use. Two residents with dialysis fistulas had blood pressure readings incorrectly documented as being taken from restricted arms, despite staff and residents confirming this did not occur. These actions did not meet the facility's policy for accurate and factual recordkeeping.
A resident with a history of choking and moderate cognitive impairment was not provided with the physician-ordered ground textured diet. Despite clear dietary orders and facility policies, the resident was repeatedly served and consumed foods such as whole unmoistened muffins, potato chips, and potatoes with skins, which are not permitted on a ground diet. Staff interviews confirmed that these items should not have been served without a physician-ordered exception, and the process for obtaining such exceptions was not followed prior to the deficiency being identified.
A resident with diabetes and depression was left alone with a cup of medications without an assessment or physician's order for self-administration. Facility staff handed the resident multiple pills and left the room, contrary to policy requiring observation and proper authorization. The DON confirmed that no assessment or order was in place for the resident to self-administer medications.
A resident admitted with multiple risk factors for skin breakdown, including a hip fracture and severe dementia, did not have a baseline care plan for skin breakdown developed within 48 hours as required by facility policy. Despite assessments indicating a very high risk and the presence of wounds and bruising, the care plan was not initiated until four days after admission, as confirmed by the DON.
Three residents did not have individualized care plans or interventions implemented for their specific needs, including hemodialysis management, hearing and vision impairments, and pressure ulcer prevention. Despite physician orders and staff awareness, care plans were either missing or not followed, and required interventions such as a Prevalon boot were not provided or documented.
A resident with a history of esophageal obstruction was not provided with the recommended mechanically altered diet after a choking incident and hospitalization. Despite hospital instructions to maintain a mechanical soft diet until GI follow-up, the resident continued to receive a regular diet. Facility staff and documentation confirmed that the diet order was not updated, and the failure to follow professional standards and hospital recommendations was acknowledged by the medical team.
A resident with Parkinson's Disease, depression, and dementia, who required staff assistance for self-care, was repeatedly observed with facial hair despite facility policy and a care plan requiring help with personal hygiene. Records showed the resident had not been shaved for an extended period, and there was no documentation of refusal or attempts to provide this care.
The Facility failed to maintain accurate medical records for two residents. One resident did not have a signed informed consent for psychotropic medication, with only verbal consent obtained. Another resident's weekly skin assessments were not documented as required. The DON confirmed the expectations for documentation were not met.
The facility failed to implement proper infection control practices, as observed in one resident unit. Nursing staff did not disinfect glucometers with bleach wipes as required, using alcohol wipes instead. Additionally, staff did not perform appropriate hand hygiene after removing contaminated gloves, touching surfaces with contaminated gloves, and failing to wash hands afterward. These actions were against the facility's infection prevention policies.
The facility failed to properly date medications with shortened expiration dates and left medication carts unlocked when unattended. Observations revealed multiple opened and undated medications in several carts, contrary to facility policy and manufacturer's guidelines. Additionally, a medication cart was found unlocked and accessible to a resident, with no staff present. Interviews with staff confirmed these practices were against the facility's protocols.
Two residents with severe cognitive impairments were not provided with their prescribed therapeutic diets, including super cereal and super mashed potatoes, during meals. Staff interviews revealed misunderstandings and unauthorized decisions regarding meal components, leading to the oversight. The DON and dietician confirmed the residents should have received the fortified foods as ordered.
A resident with dementia and Parkinson's disease was not provided with the prescribed nosey cup during meals, as observed on multiple occasions. Staff interviews confirmed the absence of the necessary adaptive equipment, despite physician orders requiring its use.
A resident with severe cognitive impairment and a pressure ulcer did not receive prescribed wound care due to the unavailability of Flagyl and Santyl. The nursing staff failed to notify the physician to alter the treatment plan, and the hospice nurse was unaware of the issue. The DON confirmed that the physician should have been informed, but the medical record lacked documentation of such notification.
A resident with anxiety and dementia, who had intact cognition, reported concerns about their roommate's behavior, including unwanted kissing. This allegation was not communicated to the DON, and no investigation was conducted, contrary to the facility's policy. The social worker was informed of the complaint but not the specific allegation of kissing, leading to a deficiency identified by surveyors.
A facility failed to follow professional standards for three residents. One resident's urinary catheter bag was not changed as ordered, another did not have a required wander guard, and a third was nearly given insulin intramuscularly instead of subcutaneously. Staff interviews revealed lapses in documentation and adherence to physician orders.
A resident with dementia and neurocognitive disorder experienced communication difficulties due to missing hearing aids. Despite a care plan requiring bilateral hearing aids, records showed the aids were missing for several days. Observations confirmed the resident often had only one hearing aid, and staff interviews revealed the right aid was lost weeks prior. Documentation practices were inadequate, as the care card and grievance binder did not reflect the resident's needs or the missing aid.
A facility failed to maintain a resident's PICC line dressing according to physician orders and professional standards. The resident's dressing was observed to be peeling and undated, with bloody drainage, and was not changed as required. The MAR lacked documentation of dressing changes on specified dates, and staff interviews confirmed the dressing should have been changed weekly and as needed.
Failure to Honor Resident’s DNR/DNI Orders Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status when the resident was found unresponsive. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR/DNI and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. On the evening in question, the resident, who had diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in their room by the assigned nurse while the nurse was bringing scheduled medications. The nurse called for help, and additional nursing staff, including a unit manager and another nurse, responded. When the unit manager asked about the resident’s code status, the assigned nurse stated the resident was a full code, based on what another nurse in the room said, without checking the physician’s orders or the MOLST. The second nurse reported that she had asked the assigned nurse about the code status and was told the resident was a full code; she also did not verify this against the resident’s records. Relying on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of chest compressions were performed. While CPR was underway, the second nurse reviewed the resident’s MOLST, discovered the DNR/DNI status, and informed the team, at which point CPR was discontinued. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they had not.
Failure to Honor DNR Order Resulting in Inappropriate CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not honoring a resident’s documented Do Not Resuscitate (DNR) status. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR, Do Not Intubate (DNI), and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. Facility policy on Cardiopulmonary Resuscitation (CPR) required staff to provide basic life support, including CPR, in accordance with the resident’s advance directives. The resident, admitted with diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in the evening when the assigned nurse entered the room to administer scheduled medications. The assigned nurse called for help, and when asked by the unit manager about the resident’s code status, the nurse stated the resident was a full code, relying on information from another nurse and without checking the physician’s orders or MOLST. The second nurse, who had also responded, assessed the resident as unresponsive, not breathing, and without a pulse, and accepted the assigned nurse’s statement that the resident was full code without independently verifying the code status. Based on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of 30 chest compressions were performed. While CPR was in progress, the second nurse reviewed the resident’s MOLST and discovered the resident’s DNR/DNI status. CPR was then discontinued after the MOLST was confirmed to belong to the resident. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they did not, resulting in resuscitative efforts being performed contrary to the resident’s documented advance directives.
Failure to Protect Resident Dignity During Hospice Care Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect, as required by its Resident Rights policy. The resident involved had diagnoses including traumatic brain injury, morbid obesity, and major depressive disorder, and was moderately cognitively impaired, required maximum assistance with ADLs, and exhibited behavioral symptoms toward others. The resident reported that on one morning a hospice aide called him/her a pig, said she would take him/her to the slaughterhouse to be slaughtered, and told him/her that he/she was a dog who used to live in a cage, which made the resident feel terrible. A CNA was present during this interaction and did not say or do anything in response, despite the resident telling the hospice aide not to call him/her names. Staff interviews corroborated multiple incidents of verbally demeaning behavior by the hospice aide toward the resident. One CNA stated that on two or three occasions, after the resident directed racial slurs and swearing at the hospice aide, the hospice aide responded by calling the resident a “fat pig,” saying they would put the resident in a butcher shop because of having so much meat, and laughing at the resident; the CNA felt uncomfortable but did not intervene or report the behavior at the time. Another CNA reported that around a holiday period, after the resident used a racial slur toward the hospice aide, the aide replied that if she was the slur, then the resident was fat, and asked how the resident liked that; this CNA also did not tell the aide that such name-calling was unacceptable and assumed the assigned CNA would report it. The ADON and DON confirmed that these CNAs later reported witnessing the hospice aide calling the resident a fat pig and fat, and the Administrator acknowledged that no one in this environment should speak to a resident in that manner, underscoring the failure to uphold the resident’s right to dignity and respect.
Failure to Implement Abuse Policy and Immediately Report Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. For one resident with dementia, osteoarthritis, and a mood disorder, a CNA reported that during a transfer to bed, she heard a slap sound followed by the resident crying out that he/she had been slapped, swearing at the CNA involved, and holding his/her face. A nurse who was outside the room also heard a slap and a scream, entered the room, asked the CNAs if the resident had been slapped, and was told no by one of them. The resident then covered his/her face and stated that his/her face had been hit and that he/she could not see. Despite this, the nurse left the room, returned to her medication cart, and allowed the CNAs to continue providing care to the resident before later instructing one CNA to report the incident, resulting in a delay of about 30 minutes from the time of the alleged slap to the report to the Nursing Supervisor. The facility’s abuse policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation, and that efforts be made to protect residents from physical and psychosocial harm, including immediate response to protect the alleged victim and removal of the alleged perpetrator. In the case of the resident who alleged being slapped, the nurse did not immediately remove the CNAs from the room or report the allegation to a supervisor at the time she heard the slap and the resident’s statement. Instead, she waited until the CNAs had finished care and left the room before questioning one CNA and directing her to report the incident, contrary to the policy’s requirement for immediate protective action and reporting. A second deficiency involved another resident with traumatic brain injury, morbid obesity, and major depressive disorder, who reported that a hospice aide called him/her a pig, said he/she would be taken to a slaughterhouse, and stated that he/she was a dog who used to live in a cage. A CNA present during these interactions stated that on two or three occasions she witnessed the hospice aide verbally abuse the resident, including calling the resident a “fat pig” and saying the resident would be put in a butcher shop because of having so much meat, then laughing. This CNA did not report any of these incidents until she was interviewed during a facility investigation. Another CNA reported witnessing the hospice aide respond to a racial slur from the resident by calling the resident fat, but initially denied any knowledge of verbal abuse when first questioned and only later disclosed the incident. These staff did not immediately report the alleged verbal abuse as required by the facility’s abuse policy, resulting in a failure to promptly report and address allegations of verbal abuse toward the resident.
Failure to Timely Report Alleged Verbal Abuse to Administration and State Agencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported alleged verbal abuse so that administration could timely notify required state agencies, as mandated by the facility’s Abuse, Neglect and Exploitation policy. That policy required all alleged violations to be reported to the Administrator, Medical Director, state agency, adult protective services, and other required agencies immediately, but no later than two hours after the allegation is made if the events involve abuse. Resident #3, whose diagnoses included traumatic brain injury, morbid obesity, and major depressive disorder, reported that on one morning around 10:00 A.M., a hospice aide called the resident a pig, said she would take the resident to the slaughterhouse to be slaughtered, said the resident was a dog who used to live in a cage, and that a CNA present in the room did not say or do anything in response. The Health Care Facility Reporting System showed that the facility’s report of an allegation of verbal abuse of this resident by the hospice aide was not created and submitted until 12/31/25 at 2:35 P.M., at least five days after one of the alleged verbally abusive incidents. Interviews with staff revealed multiple failures to promptly report the alleged verbal abuse. CNA #4 stated that on two or three occasions, beginning approximately three to four weeks prior, she witnessed the hospice aide respond to racial slurs from the resident by calling the resident a “fat pig,” saying they were going to put the resident in a butcher shop because of having so much meat, and laughing, but she did not report any of these incidents until interviewed on 01/02/26 as part of a facility investigation. CNA #5 reported that around 12/25/25, after the resident directed a racial slur at the hospice aide, the aide replied that if she was the quoted slur, then the resident was fat, but CNA #5 assumed CNA #4 would report it and initially denied any knowledge of verbal abuse when questioned by the ADON, only later admitting she had witnessed the incident. The ADON and DON confirmed that both CNAs had failed to report the alleged verbal abuse when first questioned, despite the expectation that staff immediately report allegations of abuse per facility policy, and the Administrator reiterated that staff were expected to report suspected abuse immediately so the facility could report to required agencies within two hours.
Failure to Provide and Document Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care for two of three sampled residents who were at risk for diabetes-related foot complications. For one resident with Type 2 Diabetes Mellitus and diabetic neuropathy, the Treatment Administration Record (TAR) indicated an order for daily diabetic foot care and documentation of abnormal findings. However, on three consecutive days, the assigned nurse did not provide the ordered care, citing lack of time, and failed to document the omission in the resident's medical record. On a subsequent day, another nurse signed off that the care was completed but later admitted she had not performed the care herself, instead instructing a Certified Nurse Aide (CNA) to apply lotion to the resident's feet and legs. The CNA confirmed she applied lotion as directed. For a second resident with Type 2 Diabetes Mellitus and Alzheimer's Disease, there was no documentation that nursing staff obtained a physician's order for nightly diabetic foot care upon admission, nor evidence that such care was provided. The Director of Nurses (DON) confirmed that diabetic foot care should include cleaning, inspecting, and moisturizing the feet, with proper documentation and communication of findings, and acknowledged that a physician's order should have been obtained for this resident.
Deficient Medication Storage, Labeling, and Cart Cleanliness
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. Unopened vials of Lantus and Humalog insulin were found stored in a medication cart rather than in the refrigerator as required prior to opening. Treatment supplies, such as unbagged bottles of nystatin powder, were stored alongside oral medications in the medication cart, contrary to policy that requires separation of treatments and oral medications. Additionally, medication carts were observed to be unclean, with sticky brown substances present in drawers where medications were stored, and medication bottles sticking to the residue. Further observations revealed that open vials of insulin and an Albuterol inhaler were stored in medication carts without resident identifiers and not in their original packaging. Multiple staff interviews confirmed that medications, especially insulin and inhalers, should be labeled with resident names and stored according to policy, but this was not consistently done. The Director of Nurses acknowledged that medication carts should be kept clean and medications labeled for individual resident use.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
The facility failed to store, label, and manage food in accordance with professional standards and its own policies. Surveyors observed multiple instances in the main kitchen and unit kitchenettes where food items were not dated, including opened thickened apple juice, whipped cream in a piping bag, pastries, and various containers of food and supplements. Additionally, food brought in by families was not consistently labeled with resident names, contents, or dates, and perishable items were not always discarded within the required three-day period. These lapses were confirmed by interviews with the executive chef, registered dietitian, and unit managers, who acknowledged that all food should be labeled and dated, and undated food should be discarded. Further deficiencies were noted in the storage and handling of food items. Surveyors found several dented cans of food in the dry storage area that were not labeled "do not use" or set aside as required by facility policy. There was also evidence of environmental contamination risks, such as a bug-trapping device leaking liquid above a container of oatmeal, and food items like coffee ice cream and cooking wine stored directly on the floor. Mold-like growth was observed on shelving in the walk-in refrigerator, with food stored on and below these shelves. Produce showing significant signs of decomposition, such as cabbage and herbs, was not discarded in a timely manner. The facility's own policies require that all food be covered, labeled, and dated when returned to storage, and that dented cans be removed from storage and labeled appropriately. Staff interviews confirmed awareness of these requirements, but observations indicated that these procedures were not consistently followed. The failure to adhere to food storage, labeling, and safety protocols resulted in the cited deficiencies.
Inaccurate Medical Record Documentation for Pressure Relief and Blood Pressure Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents. For one resident with severe cognitive deficits and a high risk for pressure ulcers, nursing staff documented in the Treatment Administration Record (TAR) that a Prevalon boot was applied to the right foot as ordered by the physician. However, multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. The medical record also lacked documentation of any refusal by the resident to wear the boot, despite an active physician order requiring its use at all times except for hygiene or care. For two other residents with end stage renal disease and dialysis fistulas in the left arm, the facility failed to accurately document the location of blood pressure (BP) readings. Both residents had physician orders and care plans specifying that no BP readings or blood draws should be performed on the left arm. Despite this, the electronic medical record indicated that BP readings were documented as being taken from the left arm on multiple occasions. Interviews with the residents and staff confirmed that the left arm was not actually used, and staff attributed the entries to documentation errors. The facility's own policy requires that documentation in the medical record be factual, objective, accurate, and detailed enough to reflect the resident's care and response. In these cases, the records did not accurately represent the care provided or the residents' experiences, as required by facility policy and professional standards.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with a history of choking and moderate cognitive impairment was not provided with the prescribed ground textured diet as ordered by the physician. The resident had experienced a choking episode that required an abdominal thrust, leading to a referral for a swallowing assessment by a Speech Language Pathologist (SLP). The SLP recommended a ground diet with moistened soft bread, and the physician's order specified a ground texture diet with thin liquids and moistened soft bread allowed. Facility policies and dietary manuals indicated that hard or crunchy foods, such as potato chips and potatoes with skins, should be avoided for residents on a ground diet. Despite these orders and guidelines, the resident was repeatedly observed being served and consuming food items not permitted on a ground diet, including whole unmoistened muffins, potato chips, and potatoes with skins. These observations occurred over several meals, and the resident was not offered appropriate alternatives or had their food prepared according to the prescribed modifications. The meal ticket for the resident indicated the correct diet, but the actual food served did not comply with the dietary restrictions. Interviews with facility staff, including the SLP, Food Service Director, and Unit Manager, confirmed that the resident should not have received these prohibited items without a physician-ordered exception or waiver. Staff acknowledged that the process for obtaining exceptions or waivers was not followed prior to serving the restricted foods. The medical record did not indicate that the physician was aware the resident was being served items not permitted on the prescribed diet until after the surveyor brought the issue to the facility's attention.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medication without the required assessment or physician's order. According to facility policy, residents may self-administer medications only if the interdisciplinary team determines it is safe and there is a prescriber's order. Record review showed that the resident, who has diagnoses including diabetes and depression and demonstrated intact cognition, did not have an assessment for self-administration of medications, nor was there a physician's order or care plan addressing self-administration. Observation revealed the resident was left alone in their room with a cup containing multiple pills after a nurse handed them the medication and left. The resident reported that this was a recurring practice and that they had not taken the pills yet because they wanted to ask the nurse a question. The DON confirmed that the resident had not been assessed for self-administration, the interdisciplinary team had not made a determination, and there was no physician's order in place. The DON also stated that nursing staff are expected to observe residents taking their medications and not leave medications unattended.
Failure to Initiate Baseline Skin Breakdown Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for skin breakdown within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to create a care plan with measurable goals for the prevention and management of pressure injuries after a thorough assessment. The resident in question was admitted with multiple diagnoses, including a right hip fracture, severe dementia, depression, muscle weakness, and mobility abnormalities. The admission assessment documented a dressing on the right hip, bruising on both antecubital areas, and redness under both breasts, indicating a risk for skin breakdown. The resident's skin assessment showed a score of 9, signifying a very high risk for skin breakdown, and triggered the need for a skin/wound care plan. However, the medical record revealed that the first skin/pressure/vascular ulcer care plan was not initiated until four days after the required 48-hour window. The Director of Nursing confirmed that the baseline care plan was not developed within the expected timeframe.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents with specific medical needs. One resident with end stage renal disease and dependent on hemodialysis did not have a care plan addressing hemodialysis management, including care of the dialysis access site and dietary restrictions, despite physician orders and staff acknowledgment that such a plan was necessary. The resident was cognitively intact and had clear orders regarding dialysis care, but the care plan did not reflect these needs. Another resident with sensorineural hearing loss and blindness in one eye did not have care plans addressing hearing and vision impairments. Although the resident was cognitively intact and had requested audiology and eye care consultations, and had experienced falls potentially related to these deficits, the care plan did not address these issues. Staff interviews confirmed the absence of appropriate care plans for hearing and vision needs, despite physician orders and resident requests for related services. A third resident, who had severe cognitive deficits, was dependent for all self-care, and at high risk for pressure ulcers, did not have a physician-ordered Prevalon boot applied to the right foot as required. Multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. Nursing notes did not document any refusal of the device, and staff confirmed the order was active and should have been followed, with refusals documented if applicable.
Failure to Implement Recommended Diet Following Choking Incident
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for one resident following a significant choking incident. The resident, who had a history of esophageal obstruction and food impaction, was hospitalized after choking on a piece of beef stew. Upon discharge, the hospital recommended a clear liquid diet to be advanced to a mechanical soft diet, with instructions not to progress to solid foods until a follow-up with gastroenterology (GI) was completed. However, upon the resident's return to the facility, the physician's order and dietary communication did not reflect the recommended mechanically altered diet, and the resident continued to receive a regular textured diet. Documentation in the resident's care plan and dietary records failed to indicate any change to a mechanically altered diet or any refusal of such a diet by the resident. Interviews with facility staff, including the Food Service Director and Speech and Language Pathologist (SLP), confirmed that the resident remained on a regular diet and that the hospital's dietary recommendations were not implemented. The SLP noted that it was not within her scope to override the hospital's recommendations and that the resident was educated about the ground diet option, but no formal change was made. The resident reported ongoing issues with chewing and swallowing, particularly due to broken dentures, and expressed fear of another choking incident. Further interviews with the Medical Director, the resident's physician, and the Director of Nursing revealed that all expected the hospital's dietary recommendations to be followed upon the resident's return. The Medical Director emphasized the need for clear physician orders and risk-benefit discussions if the resident chose to deviate from the recommended diet, with appropriate documentation. The physician acknowledged that a mistake occurred in not updating the diet order, and the DON agreed that the failure to change the diet placed the resident at risk. The deficiency was identified as a failure to follow professional standards and hospital recommendations for dietary management after a serious choking event.
Failure to Provide Assistance with Personal Hygiene (Facial Hair Removal)
Penalty
Summary
Nursing staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for self-care. The resident, who had diagnoses including Parkinson's Disease with dyskinesia, major depressive disorder, and dementia, required partial to substantial assistance for all self-care activities according to the most recent Minimum Data Set (MDS) assessment. Facility policy required staff to assist residents with personal hygiene, including grooming, when residents were unable to perform these tasks themselves. Despite these requirements, the resident was repeatedly observed over several days with facial hair on the upper lip and chin. Review of care records showed that the resident's care plan included assistance with personal hygiene, but there was no documentation of the resident refusing facial hair removal. The shaving care card indicated the last time the resident was shaved was nearly a month prior to the observations. Interviews with the resident and staff confirmed that shaving had not been provided as expected, and there was no documentation of refusal or attempts to provide the care.
Deficiencies in Medical Record Documentation and Consent
Penalty
Summary
The Facility failed to maintain complete and accurate medical records for two residents. For the first resident, the Facility did not obtain a signed informed written consent for the administration of psychotropic medications, specifically Lorazepam. The resident's Health Care Proxy was activated, and the Health Care Agent was responsible for making health care decisions. Despite this, the consent form for Lorazepam was only verbally obtained over the phone and was not signed by the Health Care Agent, nor did it document that the agent understood the risks and benefits of the medication. Additionally, there was no consent form for an additional dose of Lorazepam ordered later. For the second resident, the Facility's nursing documentation was incomplete regarding weekly skin assessments. The resident's care plan required weekly skin checks, but there was no documentation to support that these checks were completed on two specified dates. The Director of Nurses confirmed that nurses were expected to complete and document these checks in the electronic medical record, but this was not done for the resident on the scheduled dates.
Infection Control Deficiencies in Equipment Disinfection and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control practices on one of its resident units. Specifically, nursing staff did not adhere to the facility's policy regarding the disinfection of equipment used for multiple residents. Nurse #8 was observed using a glucometer on residents without properly disinfecting it with the required bleach wipes, instead using alcohol wipes, which is against the facility's policy. This was confirmed through interviews with the Unit Manager and the Director of Nursing, who both stated that bleach wipes must be used for disinfection after each use. Additionally, the nursing staff did not perform appropriate hand hygiene after removing contaminated gloves. Nurse #8 and CNA #3 were observed touching surfaces with contaminated gloves and failing to perform hand hygiene after glove removal. The Unit Manager and the Director of Nursing confirmed that staff are expected to follow proper glove removal techniques and perform hand hygiene before and after glove use, which was not adhered to in these instances.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in accordance with State and Federal laws, as observed during a survey. Specifically, medications with shortened expiration dates were not dated once opened in five out of six medication carts observed. Various medications, including Prostat, Trelegy ellipta inhalers, and several types of eye drops, were found opened and undated. Interviews with nurses confirmed that these medications should have been dated upon opening, as per the facility's policy and manufacturer's guidelines. The Director of Nursing also acknowledged that medications with shortened expiration dates should be dated following the pharmacy or manufacturer's directions. Additionally, the facility did not ensure that medication carts were locked when unattended. A surveyor observed an unlocked medication cart with a drawer open, accessible to a resident sitting nearby, with no staff present in the area. Nurse #8 admitted to leaving the cart unlocked while down the hall, and both the nurse and Unit Manager #2 confirmed that medication carts should be locked when not in use. The Director of Nursing reiterated that medication carts must be locked and not left open or accessible to residents.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for two residents, both of whom were severely cognitively impaired. Resident #179, diagnosed with dementia and Parkinson's disease with dyskinesia, was prescribed a diet including super cereal with breakfast and super mashed potatoes with lunch. However, observations revealed that Resident #179 was not served these fortified foods during meals on multiple occasions. Interviews with staff confirmed the oversight, with a CNA incorrectly identifying the served meal components and the DON acknowledging the failure to provide the prescribed fortified foods. Similarly, Resident #142, who has dementia and dysphagia, was prescribed a pureed diet with super cereal for breakfast and super mashed potatoes for lunch and dinner. Observations showed that Resident #142 was not served the super cereal or super mashed potatoes as ordered. A CNA mentioned that the resident was not given the fortified foods due to perceived inability to consume large amounts, a decision not discussed with the care team. The DON and dietician confirmed that the resident should have received the fortified foods as prescribed.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide the correct adaptive equipment for a resident diagnosed with dementia and Parkinson's disease with dyskinesia. The resident, who is severely cognitively impaired, requires supervision or assistance with meals and has a physician's order for a nosey cup to be used during meals. Despite this, observations on multiple occasions revealed that the resident was provided with regular cups instead of the prescribed nosey cup during breakfast and lunch meals. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, confirmed that the resident should be using a nosey cup as per physician orders. However, the CNA indicated that there were no nosey cups available for use. This lack of appropriate adaptive equipment for the resident's needs constitutes a deficiency in the facility's care provision.
Failure to Notify Physician of Unavailable Wound Care Supplies
Penalty
Summary
The facility failed to notify the physician of the unavailability of treatment supplies for a resident's daily wound care. Specifically, the nursing staff did not inform the physician when the medications Flagyl and Santyl, ordered for a resident with a pressure ulcer, were unavailable for several days. The resident, who had severe cognitive impairment and was dependent on staff for all care, was admitted with diagnoses including dementia, depression, and a pressure ulcer. The physician's orders required daily application of these medications to the resident's coccyx wound, but the medications were not available for two to four days. Despite the unavailability of these medications, the nursing staff did not notify the physician to alter the treatment plan. Nurse #2, who worked during the days the medications were unavailable, acknowledged that she did not inform the physician and should have sought an alternative treatment order. The hospice nurse was also unaware of the unavailability of the medications, and the Director of Nursing confirmed that the physician should have been notified. The medical record lacked documentation indicating that the physician was informed or that the treatment plan was adjusted due to the unavailability of the medications.
Failure to Investigate Allegation of Potential Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential sexual abuse involving a resident with anxiety and dementia, who was admitted in June 2023. The resident, who had intact cognition as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), expressed concerns about their roommate's behavior, describing them as a kleptomaniac and stating that the roommate was always kissing them. This concern was documented in a progress note dated February 8, 2024, but was not reported to the Director of Nursing or fully investigated as required by the facility's policy. The Director of Nursing was not informed of the allegation, and therefore, no investigation was initiated. Additionally, when the social worker was notified of the resident's complaint, the specific allegation of unwanted kissing was not communicated to her. During an interview, the social worker confirmed that the resident did not mention this part of the complaint when she spoke with them. This lack of communication and failure to follow the facility's policy on investigating allegations of abuse led to the deficiency identified by the surveyors.
Deficiencies in Adherence to Physician Orders and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for three residents, leading to deficiencies in care. For Resident #109, the facility did not change the indwelling urinary catheter drainage bag as ordered by the physician. The resident was admitted with diagnoses including urine retention and required an indwelling urinary catheter. Despite a physician's order to change the catheter drainage bag every Friday, the bag was observed to be dated from two weeks prior, indicating it had not been changed as required. Interviews with nursing staff revealed a lack of documentation and adherence to the physician's order. For Resident #117, the facility failed to implement a physician's order for a wander guard. The resident, who was cognitively intact, was supposed to have a wander guard applied to the right lower extremity. However, observations over several days showed the resident did not have a wander guard in place. Nursing staff were unaware of the resident's need for a wander guard, and the Treatment Administration Record inaccurately indicated checks for a non-existent device. Resident #43 experienced a deficiency in the administration of injectable medications. The resident, diagnosed with type 2 diabetes, was prescribed insulin glargine to be administered subcutaneously. However, a nurse prepared to administer the insulin intramuscularly into the deltoid muscle, which is against the physician's order. The surveyor intervened to prevent the incorrect administration, and the nurse acknowledged the mistake, citing nervousness as a factor. Interviews with the unit manager and the DON confirmed that the nurse should have known the correct method of administration.
Failure to Ensure Resident's Effective Communication Due to Missing Hearing Aids
Penalty
Summary
The facility failed to provide necessary services to ensure a resident could effectively communicate their needs. The resident, admitted in January 2023 with diagnoses including dementia, anxiety, and neurocognitive disorder, was noted to have moderate difficulty using a hearing aid. The resident's care plan required the use of bilateral hearing aids, but records indicated that the resident's hearing aids were missing for twenty-two days in May 2024. Observations confirmed that the resident often had only one hearing aid in place, and staff interviews revealed that the right hearing aid had been lost weeks prior. The facility's documentation practices were inadequate, as the care card did not reflect the resident's need for bilateral hearing aids, and the grievance binder lacked documentation of the missing hearing aid. Staff interviews highlighted a lack of awareness and communication regarding the resident's hearing aid status. The Director of Nursing acknowledged that a grievance form should have been completed and that staff should not have documented the administration or removal of both hearing aids if one was missing.
Failure to Maintain PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, as per professional standards and physician orders. The resident, who was cognitively intact and receiving intravenous medication, had a PICC line dressing that was observed to be peeling off, undated, and with bloody drainage. The facility's policy required the dressing to be changed every 7 days or immediately if compromised, but the dressing was not changed as ordered by the physician, which specified a change every Friday and as needed. The Medication Administration Record (MAR) did not indicate that the PICC line dressing was changed on the specified dates, and the progress notes did not reflect an as-needed dressing change. Interviews with nursing staff and management confirmed that the dressing should have been changed weekly and as needed, and should have been documented in the MAR. The Director of Nursing reiterated the expectation for weekly and as-needed dressing changes, which were not met in this case.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with 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.
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.
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.
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.
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 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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