East Longmeadow Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Longmeadow, Massachusetts.
- Location
- 305 Maple Street, East Longmeadow, Massachusetts 01028
- CMS Provider Number
- 225331
- Inspections on file
- 27
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at East Longmeadow Skilled Nursing Center during CMS and state inspections, most recent first.
Staff on two units did not disinfect shared medical equipment, including portable vital signs machines and glucometers, between resident uses as required by facility policy. CNAs and nurses were observed using these devices for multiple residents without cleaning them in between, and some staff admitted to not following proper disinfection procedures or not having the correct cleaning supplies available. Infection prevention policies specified the use of germicidal wipes and required cleaning after each use, but these protocols were not consistently followed.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident with a history of Cerebral Vascular Disease experienced a significant decline in ADL function, continence, and weight, but the facility did not complete the required Significant Change in Status Assessment (SCSA) as mandated by the RAI manual. The MDS Nurse acknowledged that the assessment should have been performed following the resident's decline, but it was not documented in the medical record.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A resident with a Foley catheter did not have urine output consistently documented as required by facility policy, with missing records for several shifts. Nursing staff and the unit manager confirmed that documentation was incomplete, despite orders and care plan interventions specifying that output should be recorded each shift.
The facility did not complete and transmit MDS assessments within the required timeframes for four residents, resulting in significant delays in both the completion and electronic submission of comprehensive, entry, and discharge tracking assessments, as confirmed by record review and staff interview.
The facility failed to provide a homelike dining environment for two residents. One resident with severe cognitive impairment and diabetes experienced delayed meals and public blood sugar checks, causing distress. Another resident with moderate cognitive impairment did not receive their preferred beverage, coffee, with meals. Staff interviews confirmed procedural lapses, and the facility lacked a policy on the dining experience.
The facility failed to maintain accurate and complete medical records for five residents, including documentation of hospital transfers, side rail usage, Foley catheter size, dental procedures, and wound care refusals. These deficiencies were confirmed by staff interviews and record reviews.
The facility failed to coordinate a PASARR assessment for a resident with a new diagnosis of Schizoaffective Disorder, despite the requirement to complete a new Level I assessment and refer for a Resident Review. The resident was initially admitted with Dementia and Anxiety, and the new diagnosis was not reflected in the PASARR evaluation.
The facility failed to implement a Physician's recommendation for scheduled Tylenol for a resident with severe cognitive impairment, resulting in a potential delay in pain management. Staff interviews revealed that verbal orders were not documented promptly, and necessary clarifications were not obtained.
The facility failed to follow Physician's orders for a bedbound resident's air mattress settings, consistently setting it to 325 lbs instead of the prescribed 100 lbs, despite clear instructions and reminders.
The facility allowed a resident to smoke in an undesignated area without necessary safety equipment, contrary to its smoking policy. The resident, with serious medical conditions, was observed smoking on the sidewalk without a fire extinguisher, fire blanket, or ashtray. Staff and the resident's responsible party were not informed of the designated smoking area until the survey day.
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for three residents, leading to potential infection risks. Staff did not wear the required gowns during high-contact care activities, despite EBP signage and PPE availability.
Failure to Disinfect Shared Medical Equipment Between Residents
Penalty
Summary
Staff on two units failed to follow established infection control practices for cleaning and disinfecting medical equipment between resident uses. On the 100s unit, two CNAs were observed taking vital signs from multiple residents using a portable vital signs machine without disinfecting the equipment between each resident. Both CNAs acknowledged during interviews that they either did not clean the machine between residents or only cleaned it after completing all rounds, despite being aware of the policy requiring disinfection between each use. The facility's policy specified that disinfecting wipes should be used to clean all equipment used by multiple residents, including thermometers, blood pressure cuffs, and pulse oximetry monitors. On the 400s unit, similar lapses were observed with both the vital signs machine and the glucometer. A nurse was seen using the portable vital signs machine for a resident on Enhanced Barrier Precautions and then for another resident without disinfecting the equipment in between. The nurse admitted to not having cleaning wipes available and not disinfecting the machine as required. Additionally, another nurse was observed checking blood glucose levels for multiple residents using a shared glucometer without cleaning or disinfecting the device between uses. The nurse incorrectly stated that hand sanitizer was used for cleaning the glucometer and admitted to forgetting to disinfect it between residents. Interviews with the Infection Preventionist and Unit Manager confirmed that the facility's policy required the use of specific germicidal wipes for cleaning both the vital signs machine and glucometer between each resident use, with a specified contact time for disinfection. The observed staff did not follow these procedures, and the required cleaning agents were not always readily available on the units.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in health status. The resident, admitted with a diagnosis of Cerebral Vascular Disease, initially required moderate assistance with activities of daily living (ADLs), was continent of bowel and bladder, and weighed 250 lbs. Over the course of several months, the resident's condition declined, requiring maximum assistance for ADLs, becoming occasionally incontinent of bowel and bladder, and experiencing a significant weight loss to 234 lbs. This decline was not self-limiting and affected multiple areas of the resident's health. Despite these changes, a review of the medical record showed that the required SCSA was not completed after the resident's decline. The MDS Nurse confirmed that, according to the Resident Assessment Instrument (RAI) manual, a SCSA should have been completed when the quarterly MDS assessment was performed, but it was not. The failure to complete the SCSA occurred even though the resident met the criteria for a significant change in status, as outlined in the RAI manual.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to vision and hearing services. The facility failed to ensure that the resident received necessary support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified through surveyor observation and documentation review.
Incomplete Documentation of Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who had a Foley catheter in place. According to the facility's policy, staff were required to record urinary output amounts for residents with catheters at the end of each shift and document this information in the resident's medical record. For this resident, who was admitted with diagnoses including Neurologic Neglect Syndrome, urine retention, and a history of stroke, there were multiple instances where urine output was not documented as required. Specifically, there was no documentation of urine output during certain day and night shifts over a one-week period, despite physician orders and care plan interventions that called for this monitoring. Observations confirmed the presence of a Foley catheter and the use of a privacy bag for the urinary drainage bag. Interviews with nursing staff and the unit manager revealed that documentation of urine output was incomplete and not maintained for every shift as required. The unit manager acknowledged the gaps in documentation and emphasized the importance of recording urine output to monitor for urinary retention. The lack of documentation meant that staff could not verify the resident's urinary output on the days when records were missing.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion and electronic transmission of Minimum Data Set (MDS) Assessments for four residents, as required by federal regulations. Specifically, the facility did not transmit a comprehensive MDS assessment for one resident until 141 days after completion, and an entry tracking MDS assessment for another resident was transmitted 140 days after completion. Additionally, a discharge tracking MDS assessment for a third resident was completed 19 days after the Assessment Reference Date (ARD), and an entry MDS assessment for a fourth resident was completed 27 days after the ARD. These delays were identified through record review and confirmed during an interview with the MDS Nurse, who acknowledged that the assessments were not completed or transmitted within the required 14-day timeframe. The review of the clinical records and interviews revealed that the facility was aware of the regulatory requirements outlined in the Resident Assessment Instrument (RAI) Manual, which mandates that comprehensive assessments be transmitted within 14 days of the care plan completion date and that entry and discharge tracking records be transmitted within 14 days of the event date. Despite this, the facility did not adhere to these timelines for the affected residents, resulting in significant delays in both the completion and transmission of required MDS assessments.
Failure to Ensure Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment during dining for two residents on two different units. For one resident with severe cognitive impairment and diabetes, meals were not provided timely, and blood sugar checks were conducted in the dining room instead of a private area. This resident was observed to have their blood sugar checked and insulin administered in the dining room, causing distress and refusal to eat. The resident's meal was delayed, and they were visibly upset, crying, and expressing a desire to go home. Staff interviews confirmed that blood glucose checks should be done in private, and meals should be served simultaneously to residents seated together. Another resident with moderate cognitive impairment reported not receiving their preferred beverage, coffee, with meals. Observations confirmed that coffee was not served with the resident's breakfast and lunch, and the resident had to wait for the beverage after finishing their meal. Staff interviews revealed that the coffee/tea/hot chocolate beverage cart was not passed before meal trays, as required. Additionally, there were not enough coffee mugs available, leading to further delays in serving the resident's preferred beverage. The facility lacked a policy regarding the resident dining experience, and there was a lack of coordination between the food service director and unit staff. The Director of Nursing and other staff acknowledged that residents should be served their meals and beverages timely and that the dining experience should be managed to ensure residents' preferences and needs are met. The administrator's response indicated a lack of urgency in addressing these issues, suggesting that waiting for meals and assistance was acceptable if meals were within temperature and residents did not verbalize their needs.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, leading to several deficiencies. For Resident #53, the facility did not document the resident's transfer to the hospital for a blood transfusion and their return to the facility. Despite the resident receiving two units of packed red blood cells, there was no evidence in the nursing progress notes or medical records to reflect this event. Both the Unit Manager and the Director of Nurses confirmed that the transfer and subsequent respiratory assessments should have been documented but were not. For Resident #99, the facility did not accurately document the type of side rails being used. The resident's records indicated the use of transfer bars, but observations showed that quarter side rails were in place. This discrepancy was acknowledged by the Unit Manager and the Director of Nurses, who also noted that the consent form signed by the resident's Health Care Proxy did not reflect the correct type of side rails. Resident #384's medical records showed a mismatch between the physician's order for a 16 French Foley catheter and the actual 18 French catheter in use. Similarly, Resident #42's records lacked documentation for a dental procedure and the rationale for a prescribed antibiotic. Lastly, Resident #9's refusals for weekly wound measurements were not documented, leaving a gap in the resident's clinical record from August to December 2023. The Wound Nurse admitted to not documenting these refusals, which was confirmed by the Unit Manager.
Failure to Coordinate PASARR Assessment for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR) program for one resident out of a sample of 27. Specifically, the facility did not complete a new Level I assessment for a significant change in condition and did not refer the resident for a Resident Review when the resident was diagnosed with Schizoaffective Disorder and was being treated with an antipsychotic medication. The facility's policy requires that a Level I screen be completed before admission or upon a significant change in condition and that referrals be made to the appropriate state authorities in a timely manner. Resident #76 was admitted to the facility with diagnoses including Dementia and Anxiety. The resident's initial Level I PASARR evaluation did not indicate a diagnosis of Schizophrenia. However, a psychiatric evaluation later revealed a new diagnosis of Schizoaffective Disorder. Despite this significant change, the facility did not complete a new Level I PASARR assessment or request a Resident Review from the PASARR office. The social worker acknowledged that the new assessment should have been completed but was not done as required.
Failure to Implement Physician's Recommendation for Pain Management
Penalty
Summary
The facility failed to communicate and implement a Physician's recommendation to start Tylenol medication for pain management for a resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and spinal meningioma. The Physician's recommendation was noted in progress notes but was not converted into an active order in the resident's medical record. Observations showed the resident exhibiting behaviors such as biting and fidgeting with blankets, which could indicate uncommunicated pain. Interviews with staff revealed that the Physician's orders were often given verbally and not always documented promptly. The Unit Manager and Director of Nurses acknowledged that the Physician's recommendation for scheduled Tylenol was not addressed, and the necessary clarification for dosage and frequency was not obtained. This lack of communication and documentation resulted in a potential delay in pain management for the resident.
Failure to Implement Physician's Orders for Air Mattress Settings
Penalty
Summary
The facility failed to implement the Physician's orders for the setting of a pressure-reducing air mattress for a resident with an existing pressure ulcer. The resident, who was bedbound and had diagnoses including dementia and protein-calorie malnutrition, was observed multiple times with the air mattress set to 325 lbs instead of the prescribed 100 lbs. Despite the Physician's orders and the sticker on the air mattress pump box indicating the correct setting, the mattress was consistently set incorrectly over several days of observation. Certified Nurses Aide (CNA) #5 and Nurse #5 both confirmed that the air mattress should have been set to 100 lbs as per the Physician's orders. The Unit Manager also stated that the air mattress settings were determined by the resident's weight and that stickers were placed on the pump box to remind staff of the correct settings. However, the nursing staff failed to ensure the air mattress was set correctly, leading to the deficiency noted in the report.
Failure to Provide Safe Smoking Environment
Penalty
Summary
The facility failed to provide a safe environment free from potential accidents and hazards for one resident. Specifically, the staff allowed the resident to smoke in an undesignated area on the sidewalk in front of the building without any smoking safety equipment available. The facility's policy indicated that smoking should only occur in designated locations with appropriate safety equipment, but this was not adhered to in the case of the resident. The resident, who had diagnoses including brain cancer and stroke, was observed smoking on the sidewalk with their responsible party on multiple occasions without the necessary safety measures in place. Interviews with staff and the resident's responsible party revealed that they were not informed of the designated smoking area until the day of the survey. The Unit Manager and a nurse confirmed that the resident had been smoking in an undesignated area without a fire extinguisher, fire blanket, or ashtray. The Administrator acknowledged that the sidewalk was not a designated smoking area and was unaware that the resident had been smoking there. This lack of adherence to the facility's smoking policy and failure to provide a safe environment led to the deficiency noted in the report.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were adhered to for three residents, leading to potential infection risks. For Resident #12, who had osteomyelitis and diabetic foot ulcers, a nurse did not wear a gown while performing high-contact wound care, despite the presence of an EBP sign outside the resident's room. The nurse acknowledged the oversight after being questioned by the surveyor. For Resident #17, who had severe cognitive impairment and multiple pressure ulcers, staff members did not wear gowns while repositioning the resident in bed, even though EBP signage and PPE bins were present. Both the nurse and the unit manager confirmed that gowns should have been worn during such direct care activities. Resident #42, who had moderate cognitive impairment and was at risk for pressure ulcers, was assisted with transfers and toileting by a CNA who only wore gloves and not a gown. The CNA admitted that she should have worn a gown as per the EBP requirements, given the resident's open wound and the EBP sign outside the room.
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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