Ellis Nursing Home (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwood, Massachusetts.
- Location
- 135 Ellis Avenue, Norwood, Massachusetts 02062
- CMS Provider Number
- 225211
- Inspections on file
- 22
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Ellis Nursing Home (the) during CMS and state inspections, most recent first.
A resident with a history of fracture, repeated falls, Parkinson’s disease, and paraplegia reported to family that calls for help were not being answered. A family member notified a nurse that the call light was not working; the nurse checked the system, believed it to be functioning, and did not contact maintenance at that time. Later the same day, family again found the call light unresponsive, and another family member discovered several pieces of clear tape holding down the reset button, which prevented activation of the call system. The nurse confirmed and removed the tape, and subsequent interviews with nursing leadership and maintenance verified that taping the reset button would disable the call light, though the source and timing of the taping could not be determined.
A resident with multiple pressure injuries did not receive timely or accurate wound care as recommended by a wound physician. Nursing staff continued outdated treatments and failed to promptly obtain or document new orders for specific wound care interventions, including the use of a pressure off-loading boot and heel elevation. Staff interviews revealed confusion about responsibility for following up on consultant recommendations, and management was unaware of the lapses in care.
A resident with severe cognitive impairment and a history of dementia was physically restrained in a wheelchair using a sheet by a CNA, who was concerned about the resident's repeated attempts to stand and the risk of falls. The restraint was discovered by another CNA during rounds, and the resident was found to be uninjured and not in distress. The use of the restraint was not authorized for medical treatment and was not in line with facility policy, which prohibits restraints for staff convenience or fall prevention.
A resident with dementia and severe cognitive impairment was found restrained in a wheelchair with a sheet tied around their waist. Although staff immediately removed the restraint and reported the incident internally, the DON failed to report the suspected inappropriate restraint to DPH within the required timeframe, resulting in a delay of nearly a week before the incident was officially reported.
Staff failed to consistently use PPE and perform hand hygiene when entering and exiting rooms of residents on contact precautions for infections such as MRSA and VRE. Multiple staff, including the DON, CNAs, and a housekeeper, entered rooms without donning required PPE or performing hand hygiene, despite clear signage and available supplies. During meal service, staff did not perform hand hygiene between residents or offer hand hygiene to residents before meals, and residents reported not being offered hand cleaning. These actions were not in accordance with facility policy or CDC guidelines.
Surveyors found that the facility did not create or update care plans for two residents: one with biliary drains and a portacath, and another with a heel pressure ulcer. The care plans failed to address the presence and care of these medical devices and wounds, despite physician orders and current clinical needs, as confirmed by staff interviews and record review.
Surveyors observed significant dust and debris buildup on kitchen surfaces, including air handlers, vent grates, ceiling tiles, and walk-in refrigerator shelving and fan covers. Staff interviews revealed confusion over cleaning responsibilities, and cleaning logs were marked as completed despite the presence of visible contamination. These failures resulted in the kitchen not being maintained in a sanitary and safe condition.
A resident with a history of corneal transplant and significant vision impairment did not receive timely follow-up with an eye specialist as recommended by medical providers. Despite repeated requests and documented needs, the facility failed to schedule or facilitate necessary ophthalmology appointments, resulting in missed visits and a lack of ongoing specialty care. Staff interviews revealed gaps in communication and unclear responsibility for coordinating ancillary services.
Two residents were not seen by a physician at the required intervals after admission, with all interim visits conducted by an NP for extended periods and one instance of a 74-day gap between NP visits. The DON and unit manager confirmed that physician visits were not tracked and the required alternating schedule between physician and NP was not followed.
The facility failed to prevent a decline in range of motion for a resident with Parkinson's disease, leading to bilateral hand contractures. Despite initial assessments showing no impairments, later evaluations revealed significant contractures. The care plans lacked interventions, and the resident had not received Occupational Therapy since admission. Staff interviews confirmed the oversight and lack of timely interventions.
The facility failed to develop and implement individualized care plans for five residents, leading to various deficiencies such as the absence of fall mats, inconsistent use of an orthotic device, lack of care plans for long-term antibiotics and limited range of motion, and inadequate feeding assistance for a visually impaired resident.
The facility failed to follow food safety and sanitation policies, leading to improperly labeled and undated food products and unclean equipment in four nourishment kitchenettes. Observations revealed food splatter and debris in microwaves and various food items in refrigerators without proper labeling or dates.
The facility failed to implement proper infection control practices for a resident with MRSA and during wound care for another resident. Staff did not follow CDC guidelines for TBP, did not use PPE correctly, and did not perform hand hygiene as required.
The facility failed to implement an antibiotic stewardship program, resulting in the inappropriate use of antibiotics for three residents and the lack of a documented clinical rationale for the continued use of an antibiotic for one resident. Medical records did not show any review of antibiotic use by the IP or communication to the physician or nurse practitioner.
A resident with cerebral infarction and right-sided visual impairment was repeatedly left alone in a reclining Broda chair with food spilt on their lap and clothing protector. Staff failed to provide necessary assistance or cues to help the resident eat, leaving them to self-feed dry cereal while the main meal remained untouched. Interviews with staff revealed inconsistencies in the level of assistance provided, and the Unit Manager, Assistant Director of Nursing, and Director of Nurses acknowledged the resident's dining experience was not dignified.
A resident reported missing hearing aids, but the facility failed to follow its grievance policy. The nurse did not search the room or report the issue, and the grievance was not documented. The hearing aids were found days later, highlighting a deficiency in the facility's response.
The facility failed to accurately complete the MDS assessment for three residents, leading to deficiencies in documentation. Alarms for two residents and hand contractures for another were not properly documented despite physician orders and observations confirming their presence.
A resident dependent on staff for personal hygiene had long fingernails that were not trimmed for eight weeks, despite the facility's policy requiring regular nail care. Staff interviews revealed a lack of a set schedule and proper documentation for nail care.
The facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices were utilized. Despite a baseline care plan indicating the need for hearing aids and a signed request for audiology services, the resident's clinical record lacked a care plan or physician's order for hearing aids. Observations revealed the resident often without hearing aids, leading to communication difficulties. The hearing aids were found in a medication cart, but staff were unaware of the need to offer them due to the absence of a care plan.
The facility failed to ensure that a resident was seen by a physician every 30 days for the first 90 days of admission. The resident was admitted in December 2023 and had visits on 12/27/23, 1/2/24, and 1/5/24, but the next visit did not occur until 60 days later. The Nurse Practitioner confirmed the lapse and was unaware of the 30-day requirement.
The facility failed to act promptly on a consultant pharmacist's recommendations for a stop date for Bactrim, an antibiotic medication, for a resident. Despite multiple requests in January and February, the recommendation was not addressed until March, 88 days after the medication was started. Interviews revealed a lack of oversight and follow-through on the pharmacist's recommendations.
A resident was placed on a prophylactic antibiotic without adequate clinical rationale or documentation, contrary to the facility's antibiotic stewardship policy. The resident's daughter initiated the order, and it was continued without proper re-evaluation or follow-up by the facility staff.
The facility failed to re-evaluate a resident's PRN psychotropic medication, Ativan, 14 days after it was prescribed. The order lacked a reason for use, a re-evaluation date, or a stop date. Interviews with staff confirmed that the facility's policy of limiting PRN psychotropic medications to 14 days and requiring re-evaluation was not followed.
Call Light Reset Button Taped Down, Disabling Resident Call System
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s call bell system remained functional at all times, as required by its call system policy. The policy stated that each resident must have a means to call staff from the bed and toileting/bathing areas, and that the call system must remain functional, whether audible or visual. For one resident with diagnoses including right pubic fracture, repeated falls, Parkinson’s disease, and paraplegia, the call light in the resident’s room was found to be nonfunctional because the reset button had been taped down, preventing the call light from working properly. On the date of the incident, a family member reported that the resident had been calling for help and no one answered the call light. The family member notified a nurse that the call light was not working. The nurse reported that she checked the call light by unplugging and re-plugging both call light cords in the room and found them to be working at that time. She told the family member that the call light appeared to be functioning and stated she would call maintenance if it was not working, and she also offered a handheld bell for the resident, which the family member refused according to the nurse’s account. Later that same day, the family returned and again found that the call light was not working when pressed multiple times. Another family member then pressed the call light reset button and observed that it had been taped down with several pieces of clear tape, which would prevent the system from activating. This was reported to the nurse, who went to the room, confirmed that clear tape was over the reset button, and immediately removed it. The nursing supervisor and DON were subsequently informed that tape had been found over the reset button. The maintenance director later confirmed that if tape or any pressure is placed over a call light reset button, the call light would not work or light up to call staff for assistance. Despite review of staff statements and surveillance footage, facility leadership could not determine who placed the tape on the reset button or when it was applied, but the result was that the resident’s call system was disabled and not functioning as required by facility policy.
Failure to Timely Implement and Accurately Transcribe Wound Care Orders
Penalty
Summary
Nursing staff failed to provide care and services that met professional standards of practice for a resident who was re-admitted with multiple pressure injuries. Upon re-admission, the resident had a history of diabetes mellitus with neuropathy, peripheral vascular disease, and hemiparesis, and had recently returned from a 10-day hospital stay. The wound physician made several recommendations for wound care, including specific treatments for four separate pressure injuries, but these recommendations were not promptly or accurately transcribed into physician orders or implemented by nursing staff. Review of the resident's medical record revealed that nursing continued to follow outdated and incomplete treatment orders for the resident's wounds, despite new recommendations from the wound physician. There was a significant delay in obtaining and documenting new orders for the recommended treatments, with some not transcribed until over a month after the recommendations were made. Additionally, there was a lack of documentation to support that certain wound care interventions, such as the use of a pressure off-loading boot and heel elevation, were ever implemented as recommended. Interviews with nursing staff and management indicated confusion and lack of clarity regarding responsibility for obtaining and transcribing new wound care orders. Staff members reported that the unit manager was responsible for reviewing consultant recommendations and obtaining new orders, but there was no evidence that this process was completed in a timely or accurate manner. The interim DON was unaware that the wound physician's recommendations had not been followed or that orders were not accurately transcribed.
Resident Restrained with Sheet in Wheelchair by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) used a sheet to physically restrain a resident with severe cognitive impairment in a wheelchair. The resident, who had diagnoses including dementia and generalized anxiety disorder, was dependent on staff for care and mobility and required assistance with ambulation to prevent falls. On the night in question, the CNA reported that the resident was repeatedly attempting to stand and walk unassisted, and, fearing the resident would fall, the CNA wrapped a sheet around the resident's waist and tied it to the wheelchair. The restraint was discovered during morning rounds by another CNA, who observed the resident with the sheet tied around the waist and wheelchair armrests. The resident was not in distress and had no visible injuries at the time. The assistant director of nursing (ADON) was immediately notified, observed the restraint, and directed its removal. The incident was reported to the director of nursing (DON), who confirmed that the use of the sheet constituted a physical restraint. The facility's policy defines physical restraints as any device or material that restricts freedom of movement and cannot be easily removed by the resident, and states that restraints are not to be used for staff convenience or fall prevention. The CNA involved acknowledged making a poor decision, citing the need to care for other residents and concerns for the resident's safety as reasons for the restraint. The use of the restraint was not authorized for medical treatment and was not in accordance with facility policy.
Failure to Timely Report Suspected Inappropriate Restraint Use
Penalty
Summary
The facility failed to report a suspected incident of inappropriate restraint use involving a resident with dementia and severe cognitive impairment in a timely manner, as required by policy and state law. On the morning of 05/06/25, staff discovered the resident in a wheelchair with a sheet tied around their waist and secured to the wheelchair, which was immediately recognized as a restraint. The sheet was removed, and the resident was assessed with no injuries or distress noted. The incident was promptly reported up the chain of command, from the CNA to the ADON and then to the DON. Despite the facility's policy requiring immediate reporting of suspected abuse, neglect, or inappropriate restraint to the Department of Public Health (DPH), the DON did not report the incident to DPH until almost a week later, on 05/12/25. Interviews confirmed that the DON was aware of the incident on the day it occurred but failed to make the required timely report. The delay in reporting was not explained by facility leadership, and the event was only documented in the Health Care Facility Reporting System several days after the initial discovery.
Failure to Follow Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to follow infection prevention and control practices, specifically in the areas of hand hygiene and the use of personal protective equipment (PPE) when entering and exiting resident rooms, including those on transmission-based precautions. Multiple staff members, including unit managers, nurses, the Director of Nursing, CNAs, a housekeeper, and a student volunteer, were observed entering rooms of residents on contact precautions for infections such as MRSA and VRE without donning the required PPE. In several instances, staff exited these rooms without performing hand hygiene. These lapses occurred despite clear signage and availability of PPE outside the rooms, and in contradiction to the facility's own policies and CDC guidelines for contact precautions. Residents involved included those with diagnoses of MRSA, VRE, and other infections requiring contact precautions. For example, one resident with MRSA in the nares and another with VRE in the urine had active physician orders and care plans indicating the need for contact precautions. Staff were observed disregarding these precautions, and interviews revealed inconsistent understanding among staff regarding the requirements for PPE use, with some staff incorrectly believing precautions were not necessary unless providing direct care. Additionally, the facility failed to ensure proper hand hygiene practices during meal service. Staff were observed serving meals to residents in both dining rooms and resident rooms without performing hand hygiene between residents or offering hand hygiene to residents prior to meals. This included staff handling trays, cutting food, and assisting residents with clothing protectors without cleaning their hands between tasks. Residents reported that they were not offered hand hygiene before meals, and some took it upon themselves to clean their hands. These practices were inconsistent with the facility's policy on employee hygiene and safe food handling.
Failure to Develop and Implement Individualized Care Plans for Device and Wound Management
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, resulting in deficiencies related to the management of complex medical devices and wound care. For one resident with a history of gallbladder cancer, bile duct obstruction, and recent hospitalizations, the facility did not create a care plan addressing the presence and maintenance of biliary drains and a portacath, despite clear documentation in the hospital discharge summary and active physician orders for device care. Interviews with staff revealed a lack of awareness regarding the need for a care plan for these devices, and the Director of Nursing confirmed that such devices should have been included in the resident's care plan. Another resident, admitted with dementia and a history of falls, had an unhealed heel pressure ulcer that was not reflected in the current care plan. The care plan only documented previously resolved pressure ulcers on the elbow and buttock, omitting the current heel ulcer. Staff interviews confirmed that the care plan was outdated and did not accurately reflect the resident's current skin condition, as required by facility policy and standard care practices. These deficiencies were identified through document review, observation, and staff interviews, which demonstrated that the facility did not ensure care plans were updated and individualized to address residents' current medical needs, including specialized device care and wound management. The lack of comprehensive, timely, and accurate care planning failed to meet the facility's own policies and regulatory requirements.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary and safe condition, as required by professional standards and the facility's own policies. Observations by the surveyor revealed a buildup of dust on the air handler above clean trays, large dust clumps on the vent grate, splotches of dust on ceiling tiles, and a yellow/white powdery substance and dust throughout shelving in the walk-in refrigerator. Additionally, black, raised buildup and dust were found on the condenser fan covers in the walk-in refrigerator. These findings were directly observed during multiple visits to the kitchen. Interviews with facility staff indicated a lack of clarity and responsibility regarding cleaning tasks in the main kitchen. The Food Service Director was unsure if the maintenance department was responsible for cleaning the walk-in refrigerator condenser fan covers, and both the Director of Maintenance and the Director of Housekeeping stated their departments did not perform cleaning tasks in the main kitchen. Despite weekly cleaning assignments being initialed as completed, the observed buildup and debris remained present. Staff acknowledged that vents, ceiling tiles, and shelving should be clean and free of buildup and debris.
Failure to Ensure Timely Specialty Eye Care Appointments
Penalty
Summary
The facility failed to ensure that a resident with a history of corneal transplant surgery and multiple eye conditions received recommended follow-up care with a specialty eye doctor. Despite documented recommendations from both the resident and medical providers for ongoing ophthalmology appointments, the facility did not consistently schedule or facilitate these appointments. The resident reported repeated requests for assistance in scheduling and attending eye specialist visits, but either received no follow-up or was told that staff were unavailable to escort them, leading the resident to eventually stop asking for help. Medical records and interviews confirmed that the resident had missed several scheduled and recommended eye appointments, with the last documented visit occurring in the previous year. The resident's vision continued to deteriorate, and there were missed opportunities for follow-up surgery and medication management as noted by the eye specialist's office. Facility staff, including the Unit Manager and Clinical Coordinator, were either unaware of the resident's ongoing need for specialty eye care or unable to provide documentation of efforts to ensure these services were provided. The facility's own policy required nursing staff to review and act on ancillary service recommendations, document services provided, and communicate with providers and families. However, interviews with staff revealed a lack of clarity regarding responsibility for scheduling and tracking ancillary appointments, and no evidence was found that the resident's need for continued specialty eye care was addressed in accordance with policy or medical recommendations.
Failure to Ensure Timely and Alternating Physician Visits
Penalty
Summary
The facility failed to ensure that two residents were seen by a physician at the required intervals following admission. For one resident admitted with dementia and chronic kidney disease, the initial physician visit occurred at admission, but subsequent visits were conducted solely by a nurse practitioner (NP) for over a year, with the next physician visit not occurring until more than a year later. The unit manager confirmed that physician visits were not tracked, and the director of nursing acknowledged the expectation for alternating visits between the physician and NP, which did not occur. For another resident admitted with dementia, COPD, and hypertension, the last physician visit was documented at admission, with all subsequent visits completed by the NP. There was also a gap of 74 days between two NP visits, exceeding the required frequency. The director of nursing confirmed that the expected schedule of alternating and timely visits by the physician and NP was not followed for this resident.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to prevent a decline in range of motion for a resident, leading to the development of bilateral hand contractures. The resident, who was admitted with Parkinson's disease, was observed multiple times with fingers closed to the palm and no hand positioning devices in place. Initial assessments indicated no impairments in the upper extremities, but later evaluations showed significant contractures. The care plans did not include any interventions or goals related to the resident's limited range of motion, despite the progression of symptoms and the presence of contractures noted in medical records and by staff observations. Interviews with various staff members, including nurses, a Certified Occupational Therapy Assistant, and the Director of Rehab, revealed that the resident had not received Occupational Therapy since admission. The process for addressing a decline in range of motion was not followed, as nurses did not refer the resident to the Rehab Department for assistive devices or interventions. The lack of documentation and follow-up on the resident's condition contributed to the oversight. The Director of Rehab and other staff members acknowledged the deficiency and indicated that the resident would benefit from passive range of motion exercises and the use of hand rolls to manage the contractures. However, the facility's failure to implement timely and appropriate interventions led to the resident's decline in range of motion and the development of bilateral hand contractures.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized resident-centered care plans for five residents, leading to various deficiencies. For one resident, the care plan required the use of cushioned floor mats at the bedside as a fall intervention. However, observations over several days revealed that the mats were not in place, and the care plan was not updated to reflect the removal of the mats. The Unit Manager confirmed that the care plan should have been updated if the mats were no longer part of the plan of care. Another resident had a care plan that included the use of a right-hand orthotic device to prevent worsening hand contracture. Despite this, the resident was observed multiple times without the device, and the staff failed to ensure its consistent use. The Director of Nursing (DON) acknowledged that the staff should have placed something in the resident's hand to prevent further decline in range of motion and maintain skin integrity. Additional deficiencies included the failure to develop a care plan for a resident on long-term antibiotics for urinary tract infection prophylaxis, the lack of a care plan for a resident with limited range of motion, and the failure to assist a visually impaired resident with feeding during meals. These failures were confirmed through interviews with staff and observations, indicating that the facility did not follow its policies for comprehensive, person-centered care plans.
Failure to Follow Food Safety and Sanitation Policies
Penalty
Summary
The facility failed to follow their policy and professional standards of practice for food safety and sanitation, leading to the potential spread of foodborne illness to residents. Specifically, the facility did not properly label and date food products and failed to maintain clean equipment in four nourishment kitchenettes. Observations revealed that microwaves in the Applewood, Elmwood, Driftwood, and Cherrywood Unit Kitchenettes had food splatter and debris, and some had structural damage. Additionally, various food items in the refrigerators were found without proper labeling or dates, including opened packages of candy, beverages, and juices, as well as pieces of pizza wrapped in aluminum foil without identification or dates. The Food Service Director (FSD) stated that nourishment kitchenettes are cleaned and stocked daily by dietary aides, who are responsible for discarding improperly labeled items. The FSD also mentioned that a deeper cleaning of the unit refrigerators and freezers is conducted twice a week. However, the observations indicated that these procedures were not being followed consistently. The Housekeeping Manager confirmed that his department is responsible for cleaning the microwaves daily and acknowledged that the condition of the microwaves was not acceptable. The facility's policy titled 'Food Safety for Your Loved One' outlines the requirements for labeling and dating food and beverages to monitor food safety. The policy also specifies that food and beverages with handwritten labels should be discarded three days after the date marked, and items beyond the manufacturer's expiration date should be thrown away. Despite these guidelines, the facility failed to adhere to its own policies, resulting in multiple instances of non-compliance across different units.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) according to CDC guidance for a resident with MRSA infection. Despite a Contact Precautions sign posted at the entrance to the resident's room, staff members were observed entering and exiting the room without wearing gloves or gowns and without performing hand hygiene. The resident's medical record indicated the need for Contact Precautions, but staff members demonstrated confusion between Enhanced Barrier Precautions (EBP) and Contact Precautions, leading to improper use of personal protective equipment (PPE) and hand hygiene practices. Interviews with staff revealed a lack of understanding and adherence to the facility's infection control policies and CDC guidelines for TBP and hand hygiene. The Director of Nurses confirmed that staff should follow the posted signs and use full PPE and hand hygiene as required by Contact Precautions. Additionally, the facility failed to ensure proper infection control practices during wound care for another resident. A nurse was observed performing wound care without cleaning the overbed table, removing the resident's sock with bare hands, and failing to perform hand hygiene before putting on gloves. Another staff member touched the resident's foot with gloved hands and then handled the resident's eyeglasses without changing gloves or performing hand hygiene. The Director of Nurses acknowledged that hand hygiene should be performed before putting on gloves and after removing them, and that gloves should be changed between different tasks to prevent cross-contamination.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and monitoring in line with the facility's policies. Specifically, the facility did not ensure the monitoring of antibiotic use that did not meet criteria for antibiotic treatment for three residents. Additionally, the facility did not provide a stop date or clinical rationale for the continued use of an antibiotic for one resident. For three residents, the facility's tracking documents indicated that antibiotics were prescribed for urinary tract infections (UTIs) without meeting the McGeer criteria. The medical records for these residents did not show any review of the antibiotic use by the Infection Preventionist (IP) or designee, nor was there any communication to the physician or nurse practitioner. Interviews with the Director of Nursing (DON) and Staff Development Coordinator (SDC) confirmed that no documentation of antibiotic reviews was available. One resident was admitted with a history of UTIs and was placed on a prophylactic antibiotic without a documented clinical rationale. The medical records and progress notes failed to indicate the need for the continued use of the antibiotic, and there was no documentation from the Urologist's office supporting the prophylactic treatment. Interviews with nursing staff revealed that there was no clear documentation or communication regarding the rationale for the long-term use of the antibiotic.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for Resident #70, who has a history of cerebral infarction with hemiparesis and hemiplegia, visuospatial deficit, and failure to thrive. The resident was observed multiple times sitting alone in a reclining Broda chair in the corner of the day room, slumped over, with food spilt on their lap and clothing protector. Staff did not intervene to clean up the spilt food, provide another meal, or assist the resident with eating. The resident's meal was often placed on an overbed tray table, with the main plate on the right side, despite the resident's right-sided visual impairment, making it difficult for them to see and reach the food. Staff failed to provide necessary assistance or cues to help the resident eat, leaving them to self-feed dry cereal while the main meal remained untouched. Additionally, the resident was left with food on their lap and clothing protector for extended periods without staff intervention. Interviews with staff members revealed inconsistencies in the level of assistance provided to the resident, with some staff stating that assistance depended on the resident's mood or the day. The Unit Manager and Assistant Director of Nursing acknowledged that the resident should not be left alone with food on their lap and should be provided with assistance to eat, especially given their right-sided visual impairment. The Director of Nurses also confirmed that the resident's dining experience was not dignified and that staff should have provided better assistance.
Failure to Timely Address Resident's Grievance Regarding Missing Hearing Aids
Penalty
Summary
The facility failed to formulate a grievance timely for concerns brought forward by a resident regarding missing hearing aids. The resident, who was admitted with diagnoses including cerebral infarction with hemiparesis and hemiplegia affecting the left side, reported the missing hearing aids to a nurse. Despite the facility's policies requiring immediate action, the nurse did not search the room or report the missing items to the appropriate personnel, including the unit manager, social worker, director of nursing, or administrator. The grievance was not documented in the grievance book, and no nursing progress notes indicated the missing hearing aids. Interviews with staff revealed that the nurse had not initiated a search or reported the missing hearing aids, contrary to the facility's policies. The unit manager and assistant director of nursing were unaware of the missing hearing aids until days later. The unit manager emphasized that all departments should be notified immediately to search for the missing items, and a grievance form should be filled out promptly. The assistant director of nursing and the director of nursing both confirmed that the grievance process should be initiated immediately, and the room should be searched without delay. The resident had to wait several days before the hearing aids were found, which was contrary to the facility's policies and procedures. The director of nursing highlighted the importance of addressing such issues promptly to prevent potential loss or damage to essential items like hearing aids. The failure to follow the grievance policy and timely address the resident's concern led to a deficiency in the facility's handling of the situation.
Inaccurate MDS Documentation for Three Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for three residents, leading to deficiencies in documentation. For Resident #106, who was admitted with diagnoses including acute on chronic congestive heart failure and frequent falls, the MDS did not indicate the use of bed and chair alarms despite physician orders and daily checks confirming their use. Observations by the surveyor confirmed the presence of these alarms, and the MDS Nurse acknowledged the error upon review. Similarly, Resident #107, admitted with dementia and muscle weakness, had physician orders and daily checks for bed and chair alarms, which were also observed in use by the surveyor. However, the MDS failed to document these alarms, and the MDS Nurse confirmed the need for modification after review. For Resident #52, admitted with Parkinson's disease, the MDS inaccurately reported no impairments in upper extremities despite physician notes and observations indicating bilateral hand contractures. The MDS Coordinator confirmed the inaccuracy upon review of the medical record and observation of the resident.
Failure to Provide Proper Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident who was dependent on staff for personal hygiene. The resident, admitted in July 2020, had long fingernails observed by a surveyor on two consecutive days. The facility's policy required daily cleaning and regular trimming of nails, but the resident's nails had not been cut for eight weeks. Interviews with staff revealed that there was no set schedule for nail care, and documentation of nail care was lacking in the resident's flow sheets. The resident's spouse confirmed that the resident's nails were too long and mentioned that the resident would pull their hands away during nail cutting, requiring two staff members for the task. Despite this, the nails were not trimmed regularly. The Unit Manager and CNAs acknowledged the issue, with one CNA stating that she cut the resident's nails only after the surveyor's observation. The lack of a clear schedule and proper documentation contributed to the deficiency in nail care for the resident.
Failure to Provide Hearing Aids and Audiology Services
Penalty
Summary
The facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication. Resident #86, who was admitted with a diagnosis of dementia and identified as hearing impaired, had a baseline care plan indicating the need for hearing aids. Despite this, the resident's clinical record lacked an impaired communication care plan, and there was no physician's order for the use of hearing aids. The resident's representative had signed a form requesting audiology services, but these services were not provided during the resident's stay at the facility. Multiple observations and interviews revealed that the resident was often without hearing aids, leading to significant communication difficulties. On several occasions, the resident was observed without hearing aids, struggling to communicate effectively with staff and other residents. The hearing aids were found in the top drawer of the medication cart, but staff were unaware of the need to offer them to the resident due to the absence of a care plan or physician's order. The unit manager acknowledged that the consent for audiology services should have been faxed over upon admission, but this was not done. The resident's ability to communicate improved significantly when the hearing aids were used, as observed during a dining room interaction. However, the lack of consistent use of the hearing aids and the failure to provide requested audiology services constituted a deficiency in the resident's care.
Failure to Ensure Timely Physician Visits for New Admission
Penalty
Summary
The facility failed to ensure that Resident #28 was seen by a physician every 30 days for the first 90 days of admission. Resident #28 was admitted in December 2023 and was seen for an initial visit on 12/27/23, followed by visits on 1/2/24 and 1/5/24. However, the next visit did not occur until 3/6/24, which was 60 days after the previous visit. During an interview, the Nurse Practitioner confirmed that no additional visits were conducted between 1/5/24 and 3/6/24 and stated that she was unaware of the requirement for new admissions to be seen every 30 days for the first 90 days.
Failure to Act on Pharmacist's Recommendations for Medication Stop Date
Penalty
Summary
The facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one resident out of a total sample of 26 residents. Specifically, the facility did not ensure that the January 2024 and February 2024 consultant pharmacist's recommendations for a stop date for Bactrim, an antibiotic medication, were acted upon in a timely manner. The resident had been administered Bactrim daily since December 2023 for a urinary tract infection (UTI), and the pharmacist had made multiple requests for a stop date, which were not addressed until March 2024, 88 days after the resident started the medication and 57 days after the initial recommendation. Interviews with facility staff revealed a lack of oversight and follow-through on the pharmacist's recommendations. The Unit Manager was new to the role and unaware of the previous recommendations, while the Assistant Director of Nurses (ADON) stated that she does not oversee the MRRs. The Director of Nurses (DON) acknowledged that the pharmacy recommendations should be addressed and documented but was unable to speak specifically about the recommendations as she was not employed at the facility at the time. This lack of timely action and documentation led to the deficiency identified in the report.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically an antibiotic. Resident #20, who was admitted with diagnoses including a urinary tract infection (UTI), chronic kidney disease, and other conditions, had completed a course of antibiotics for a UTI prior to admission. Despite this, the resident was placed on a prophylactic antibiotic, Bactrim, without adequate clinical rationale or documentation from the prescribing Urologist. The facility's policy on antibiotic stewardship was not followed, as there was no documented indication for the continued use of the antibiotic, and the order lacked a clear stop date or clinical justification for long-term use. The medical record review revealed that the resident had been receiving Bactrim daily since December 2023, but there was no documentation supporting the need for prophylactic antibiotics. Interviews with facility staff, including the Unit Manager and Assistant Director of Nurses, confirmed that there was no communication with the Urologist's office to verify the necessity of the antibiotic. The Director of Nurses stated that the expectation was for the rationale for long-term antibiotic use to be documented and for there to be a trial dose reduction, neither of which occurred in this case. The deficiency was further highlighted by the fact that the resident's daughter had initiated the antibiotic order, and it was continued without proper re-evaluation or follow-up by the facility staff. The facility's failure to adhere to its antibiotic stewardship policy and ensure appropriate documentation and clinical justification for the use of prophylactic antibiotics led to the resident receiving unnecessary medication, contrary to the facility's guidelines and best practices for medication management.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Ativan, was re-evaluated 14 days after it was prescribed. The resident, who was admitted in June 2023 and had diagnoses including failure to thrive, major depressive disorder, and dementia, was on hospice services. The medical record indicated a handwritten order for Ativan on 3/29/24, but it lacked a reason for use, a re-evaluation date, or a stop date. The physician's orders also failed to include a re-evaluation or stop date for the PRN medication. Interviews with the Nurse Practitioner, Unit Manager, and Director of Nurses revealed that the facility's policy of limiting PRN psychotropic medications to 14 days and requiring re-evaluation was not followed. The NP acknowledged the omission, stating she was aware of the 14-day requirement but did not implement it. The Unit Manager and Director of Nurses confirmed that the policy was not adhered to, despite the resident being on hospice services.
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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