Eliot Center For Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Natick, Massachusetts.
- Location
- 168 West Central Street, Natick, Massachusetts 01760
- CMS Provider Number
- 225516
- Inspections on file
- 17
- Latest survey
- January 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eliot Center For Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to involve residents and their representatives in the care planning process, as required by policy. Quarterly care plan meetings were not conducted for several residents, and there was no evidence of invitations to these meetings. Residents with various diagnoses, including dementia and cancer, were affected, and staff confirmed the absence of required meetings and documentation.
The facility did not post daily nurse staffing information in a prominent location for three consecutive days and failed to retain 18 months of staffing records. The Administrator and VP of Operations acknowledged the requirements but could not provide the necessary documentation.
The facility failed to maintain food safety and sanitation standards, risking foodborne illness. Spoiled and unlabeled food was found in the kitchen, and unsanitary conditions were observed in the dining room. Staff mixed clean and dirty items at a drink station, and an Activities Assistant used contaminated ice for a resident's drink. The DON intervened, and interviews revealed lapses in staff training and protocol adherence.
A resident's enteral feeding pump pole was found visibly soiled with a dried, milky substance over three days, indicating a failure to maintain cleanliness. The resident, with severe cognitive impairment and dependent on enteral feeding, was observed by a surveyor, and both a CNA and the ADON acknowledged the unclean state of the equipment. The facility's policy required cleaning of visibly soiled equipment, which was not followed in this case.
A resident's communication tablet went missing, and the facility failed to resolve the grievance promptly. Despite staff awareness, the grievance was not documented or addressed according to policy. The resident, with aphasia and major depressive disorder, relied on the tablet for communication. The grievance form was incomplete, and the Administrator was unaware of the issue.
A facility failed to accurately code the MDS Assessment for a resident's dental status. The resident, with severe cognitive impairment, was observed to have significant dental issues not reflected in the assessment. The DON and MDS Nurse admitted the assessment was based on outdated information without a current examination.
Two residents dependent on staff for personal hygiene tasks did not receive necessary grooming assistance, including fingernail and facial hair care. Despite care plans indicating the need for staff assistance, observations revealed long and unkempt nails and facial hair. The DON confirmed the oversight, and CNAs admitted to not addressing these needs during routine care.
A facility failed to provide an emergency dialysis kit for a resident with Chronic Kidney Disease Stage 5, who required renal dialysis. The absence of the kit, which should have included clamps and pressure dressings, was noted during a survey. The resident had a central venous catheter, and the facility's policy required staff to be trained in handling such emergencies. However, a nurse was unaware of the resident's specific care needs, and the Director of Nursing admitted the clamp was used elsewhere and not returned.
A facility failed to implement a Consultant Pharmacist's recommendation to update a Physician's order for a resident with COPD using Budesonide. The recommendation, which was agreed upon by the physician, advised instructing the resident to rinse their mouth after use to prevent oral thrush. The Director of Nursing acknowledged the oversight during an interview.
A nurse failed to secure medications during a medication pass, leaving a cart unlocked and unattended in the hallway. This occurred while administering medications to a resident, with other residents and staff nearby. The DON expressed concerns about the safety of this practice, as it deviated from the facility's policy on medication storage.
A resident with severe cognitive impairment and dental issues did not receive requested dental services due to the facility's failure to refer them to the dental services vendor. Despite the guardian's request and multiple visits from the on-site dental service, the resident was not seen, leading to a deficiency in care.
A facility failed to adhere to infection control standards for a COVID-19 positive resident. Staff did not wear required eye protection and failed to perform hand hygiene after glove removal, despite facility policies and signage indicating necessary precautions. The DON acknowledged these lapses in protocol.
The facility failed to accurately complete PASARR screenings for two residents, resulting in missed Level II evaluations for serious mental illnesses. One resident was admitted with psychiatric diagnoses and recent psychiatric treatment, yet the PASARR indicated no SMI. Another resident's recent psychiatric treatment was not reflected in the PASARR, despite being prescribed psychotropic medications. Staff interviews revealed non-compliance with the facility's PASARR policy, leading to deficiencies in identifying and evaluating the need for specialized services.
Failure to Involve Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided the right to participate in the care planning process, as required by their policies. Specifically, the facility did not conduct quarterly care plan meetings for four residents, nor did they invite the residents or their representatives to participate in these meetings. The facility's policy mandates that the Interdisciplinary Team (IDT) should include the resident or their representative and that care plan meetings should be held at a convenient time for them. However, there was no documented evidence of such meetings or invitations for the residents in question. Resident #40, admitted with Adjustment Disorder and Dementia, had no documented evidence of care plan reviews by the IDT following MDS assessments in May and September 2024. The MDS Nurse confirmed the absence of care plan meetings involving the resident or their representative. Similarly, Resident #89, with diagnoses including Malignant Neoplasm of the Prostate and Dementia, had no evidence of IDT care plan meetings following the November 2024 MDS assessment, despite being listed on the facility's care plan meeting schedule. Resident #57, with conditions such as COPD and Diabetes Mellitus, reported never attending care plan meetings, and there was no evidence of such meetings following the August 2024 MDS assessment. Lastly, Resident #22, with Malignant Neoplasm of the Brain and Multiple Sclerosis, had no documented participation in care plan meetings scheduled for April and July 2024. The resident's Health Care Proxy confirmed not being invited to these meetings. The MDS Nurse and Regional MDS Nurse acknowledged the lack of evidence for the required meetings and invitations.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent and accessible location for residents and visitors. During a recertification survey, it was observed that the facility did not have the required nurse staffing information posted on three consecutive days. The Administrator acknowledged the requirement but was unable to provide evidence of the postings for the specified dates. Additionally, the facility did not maintain 18 months of daily nurse staffing records as required. The Vice President of Operations confirmed the location where the staffing information should be posted but admitted that the facility did not have the necessary records retained for the required duration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, leading to potential foodborne illness risks for residents. During an inspection, surveyors observed spoiled and improperly labeled food items in the facility's kitchen. Specifically, cucumbers with a moldy film and ground beef past its use-by date were found in the walk-in and reach-in refrigerators, respectively. Additionally, sandwiches were stored without proper labeling or dating. Dietary staff acknowledged that these items should have been discarded or properly labeled, as per the facility's food safety policies. In the main dining room, surveyors noted unsanitary conditions during meal service. A drink station was set up with clean and dirty items improperly mixed. Nursing staff served drinks from this station, where dirty cups and utensils were placed alongside clean ones. An Activities Assistant was observed using a clean cup to scoop ice from a contaminated container, which was then served to a resident. The Director of Nursing intervened to prevent the resident from consuming the contaminated drink and educated the staff member on proper procedures. Interviews with the Corporate Food Service Director and the Director of Nursing revealed lapses in staff training and adherence to food safety protocols. The Corporate FSD confirmed that dirty items should not have been on the same table as clean items, and that staff should not have used contaminated ice. The DON expressed uncertainty about whether the staff member involved had received adequate training in safe food handling practices.
Failure to Maintain Cleanliness of Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was dependent on enteral feeding. The deficiency was identified when a surveyor observed the resident's enteral feeding pump pole, which was visibly soiled with a dried, milky-colored substance at the base. This observation was made over three consecutive days, indicating a lack of timely cleaning and maintenance of the equipment. The facility's policy required that enteral feeding poles be cleaned if visibly soiled and routinely, but this was not adhered to in this instance. The resident involved had been admitted to the facility with diagnoses including dysphagia and gastrostomy status, and had severely impaired cognitive skills, rarely understanding or being understood by others. During an interview, a CNA acknowledged that the base of the pole was dirty and should have been cleaned immediately after the spill occurred. The CNA noted that the nursing staff responsible for the spill should have wiped it up, as they had access to wipes for cleaning. The Assistant Director of Nurses also confirmed the pole was dirty and stated that both housekeeping and nursing staff were responsible for maintaining cleanliness, emphasizing the importance of immediate spill cleanup to prevent pest attraction and maintain a proper environment.
Failure to Resolve Grievance for Missing Communication Device
Penalty
Summary
The facility failed to ensure prompt efforts to resolve a grievance for a resident who had a communication device reported missing. The resident, who was admitted with conditions including aphasia and major depressive disorder, relied on an electronic communication tablet to communicate with staff. The grievance policy of the facility mandates that grievances be addressed promptly, but in this case, the grievance regarding the missing tablet was not resolved in a timely manner. The resident's communication tablet, which was essential for making needs known, was reported missing by nursing staff. Despite the awareness of the missing device by various staff members, including a Certified Nurses Aide and the Speech Therapist, the grievance was not properly documented or addressed. The grievance form, completed by a supervising nurse, was found incomplete with no evidence of action taken, responsible person, or follow-up documented. The form was located in the binder of a contracted social worker who was no longer with the facility. Interviews with staff revealed that the grievance process was not followed as required. The Administrator, who was the Grievance Officer, was unaware of the missing device and had not received a grievance form related to it. The Assistant Director of Nurses acknowledged that the grievance had been discussed in staff meetings but was unsure of any subsequent actions. The failure to address the grievance promptly and effectively highlights a breakdown in the facility's grievance resolution process.
Inaccurate MDS Assessment Coding for Dental Status
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) Assessment for a resident, specifically regarding dental status. The resident, admitted in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol, was found to have discrepancies in the MDS Assessment completed on November 8, 2024. The assessment inaccurately indicated no dental issues, despite observations by the surveyor and the Director of Nursing (DON) revealing that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. During interviews, it was revealed that the MDS coding for the resident's dental status was not based on a current examination. The DON admitted that the assessment was completed by an off-site MDS Nurse, and there was no evidence that any staff member or the MDS Nurse had examined the resident's mouth for dental status. The MDS Nurse confirmed that the responses for dental status were carried over from a previous assessment completed on November 13, 2023, without verification, leading to the inaccurate coding.
Failure to Provide Grooming Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents who were dependent on staff for personal hygiene tasks. Resident #15, who was admitted with multiple diagnoses including unspecified dementia and major depressive disorder, was observed on two occasions with long facial hair and fingernails with debris, despite being dependent on staff for these grooming tasks. The resident's care plan indicated a need for assistance with personal hygiene, yet the Certified Nurses Aides (CNAs) responsible for the resident's care did not provide the required grooming services during morning and evening care. Similarly, Resident #57, who was admitted with conditions such as chronic obstructive pulmonary disease and diabetes mellitus, was observed with long and jagged fingernails on two separate occasions. The resident's care plan required staff assistance for personal hygiene, including fingernail care, but the CNAs failed to provide this care during scheduled grooming times. The resident expressed a need for fingernail trimming, yet the care was not provided until later in the day after the deficiency was noted by the surveyor. The Director of Nursing (DON) acknowledged the oversight in both cases, confirming that the grooming tasks were part of the residents' care plans and should have been addressed during routine care. The CNAs involved admitted to not noticing or addressing the grooming needs during their shifts, resulting in the residents not receiving the necessary personal hygiene care as outlined in their care plans.
Failure to Provide Emergency Dialysis Kit for Resident
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not ensure that an emergency kit, including clamps and pressure dressings, was kept with the resident and at the resident's bedside as ordered. This deficiency was observed during a survey when the surveyor, along with the resident's family member, noted the absence of the emergency kit in the resident's room. The resident, who was admitted with Chronic Kidney Disease Stage 5 and dependent on renal dialysis, had a central venous catheter in the chest, necessitating the availability of the emergency kit. Further investigation revealed that the facility's policy required staff to be trained in recognizing and intervening in medical emergencies related to dialysis care. However, during an interview, a nurse was unaware of the resident's specific care needs and the location of the venous catheter access site. The Director of Nursing acknowledged that the clamp should have been at the resident's bedside but was used for another resident's wound care and not returned. This oversight highlights a lapse in adherence to the facility's policy and the physician's orders for the resident's care.
Failure to Implement Pharmacist's Recommendation for Medication Management
Penalty
Summary
The facility failed to act upon a recommendation made by the Consultant Pharmacist during a monthly Medication Regimen Review for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was prescribed Budesonide, an inhaled steroid medication, and the Consultant Pharmacist recommended updating the Physician's order to include instructions for the resident to rinse their mouth after use to prevent oral thrush. This recommendation was reviewed and agreed upon by the resident's physician but was not implemented in the resident's Physician's orders. During an interview, the Director of Nursing (DON) acknowledged that the recommendation should have been added to the resident's Physician's orders to prevent the development of thrush, but it had not been done. The facility's policy indicates that consultants provide written, dated, and signed reports of each consultation visit, which include recommendations and plans for implementation. However, the facility did not follow through with the Consultant Pharmacist's recommendation, leading to a deficiency in ensuring proper medication management for the resident.
Medication Storage Deficiency During Medication Pass
Penalty
Summary
The facility failed to ensure that medications were stored securely and in accordance with accepted professional standards during a medication pass for a resident. Nurse #1 prepared medications on top of a medication cart in the hallway outside the resident's room. The medications included oral medications, a nasal spray, and an inhalation medication. Nurse #1 left the medication cart unattended and unlocked in the hallway multiple times while administering medications to the resident in their room. This left the medications accessible to unauthorized staff and residents present in the hallway. During the medication pass, Nurse #1 repeatedly left the medication cart unlocked and unattended, with medications on top of the cart, while entering the resident's room to administer the medications. The Director of Nursing expressed concerns about the safety of leaving medication carts unlocked and unattended, emphasizing that medications should be secured and carts locked when not in use or unattended. Nurse #1 admitted to leaving the cart unlocked for convenience, indicating a deviation from the facility's policy on medication storage.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, despite a request from the resident's guardian. The resident, who was admitted with diagnoses including unspecified dementia, insomnia, anxiety, and high cholesterol, did not have any dental care problems, goals, or interventions included in their care plan. The facility's policy stated that routine and emergency dental services were available through a contract with a licensed dentist. However, the resident's guardian requested dental services in July 2024, and the resident was not referred to the dental services vendor, even though the on-site dental service had visited the facility multiple times since the request. Observations and interviews revealed that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. The resident mentioned that their other teeth were at home and expressed that their teeth did not hurt. The Director of Nursing (DON) acknowledged that the resident should have been referred for dental services as requested but was not. This oversight resulted in the resident not receiving the necessary dental care, despite the facility's policy and the guardian's request.
Infection Control Deficiency in COVID-19 Positive Resident's Care
Penalty
Summary
The facility failed to adhere to infection control standards for a resident who tested positive for COVID-19. The resident, admitted in April 2004 with a diagnosis of Paranoid Schizophrenia, was placed under contact and droplet precautions due to a positive COVID-19 test. The facility's policy required staff to wear appropriate PPE, including gloves, gowns, masks, and eye protection, and to perform hand hygiene after removing gloves. However, observations revealed that staff did not consistently follow these protocols. On two separate occasions, staff members entered the resident's room without wearing the required eye protection, despite signage indicating the need for such precautions. A housekeeper was observed cleaning the room without goggles and failed to perform hand hygiene after removing gloves. Similarly, a CNA entered the room without eye protection, citing unavailability, although goggles were present in the PPE bin. The Director of Nursing confirmed that both staff members should have worn eye protection and that the housekeeper should have performed hand hygiene after glove removal.
Failure to Complete Accurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to accurately complete Level I Preadmission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in identifying and evaluating serious mental illnesses (SMI) or intellectual disabilities (ID/DD). For one resident, the PASARR indicated no SMI, despite the resident being admitted with diagnoses of Major Depressive Disorder, Unspecified Psychosis, PTSD, and Anxiety, and having received psychiatric services during a recent hospitalization. The facility did not complete a Level II PASARR Evaluation as required, which should have been triggered by the resident's psychiatric diagnoses and recent psychiatric treatment. Another resident was admitted with diagnoses of PTSD and Major Depressive Disorder. The PASARR Level I Screening failed to acknowledge the resident's recent psychiatric treatment during hospitalization, which included agitation, mood lability, and pseudobulbar affect symptoms. Despite being prescribed Zyprexa and Prozac for these symptoms, the PASARR did not reflect the need for a Level II evaluation, which would have determined the necessity for specialized services for SMI. Interviews with facility staff revealed a lack of adherence to the facility's PASARR policy, which mandates accurate screening and reporting of psychiatric diagnoses upon admission. The MDS Nurse and Director of Nursing acknowledged the oversight in the PASARR process for the first resident, while the Admissions Liaison and Social Worker recognized the need for a Level II evaluation for the second resident based on the hospital discharge summary. These failures resulted in the residents not receiving the necessary evaluations and potential specialized services for their mental health conditions.
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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