Fall River Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 1748 Highland Avenue, Fall River, Massachusetts 02720
- CMS Provider Number
- 225723
- Inspections on file
- 29
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Fall River Healthcare during CMS and state inspections, most recent first.
The facility failed to uphold residents’ rights to dignity and respectful treatment when a severely cognitively impaired resident with psychotic disorder and Alzheimer’s repeatedly initiated non-consensual physical contact with two other severely cognitively impaired residents, one with unspecified dementia and psychotic disturbance and another with cerebral infarction and adjustment disorder with anxiety. Over multiple occasions, this resident kissed and hugged other residents, massaged a resident’s shoulders, and later touched another resident’s breast and groin area over clothing, all without consent. Social workers reported that, despite counseling on personal boundaries, the resident appeared to forget the discussions almost immediately, and the DON reported that one affected resident was visibly upset and shaken after the incident involving touching of the breast and groin.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
A resident with dementia and depression received an antidepressant medication without documented evidence that their health care proxy was informed of the benefits, risks, and alternatives, as required by facility policy. Staff confirmed that the necessary consent form was missing from the resident's record and that the health care proxy should have provided consent prior to starting the medication.
A resident with schizoaffective disorder, bipolar disorder, and anxiety disorder was admitted to psychiatric hospitals on two occasions, but the facility did not notify the state PASRR agency or submit the required post-admission Level II evaluation after these events, as confirmed by record review and staff interview.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident with a history of hearing loss and documented worsening hearing impairment did not receive a referral for audiology services, despite repeated complaints, care plan interventions, and a physician's order for audiology consultation. Staff interviews and record review confirmed that the resident was not scheduled for the facility's audiology visit, and the need for referral was not documented or acted upon.
A resident with a chronic stage 4 pressure ulcer did not receive wound care as ordered by the wound consultant physician, specifically missing the prescribed collagen dressing in their treatment. Nursing staff continued to provide the previous treatment regimen, and the updated orders were not entered into the electronic medical record or carried out, as confirmed by staff interviews and record review.
A resident in an LTC facility was verbally abused by two CNAs during the night shift. The resident, who was frequently incontinent and dependent on staff for care, reported feeling humiliated and upset after the CNAs yelled and made derogatory comments about their incontinence. The resident's roommate corroborated the account, and both CNAs initially denied the allegations but later accused each other of the abusive behavior.
A CNA verbally and mentally abused three residents during a night shift, causing distress and fear. The CNA yelled, swore, and made derogatory remarks, which were witnessed by staff. One resident reported being afraid, while another cried due to the CNA's behavior. Despite witness accounts, the facility did not substantiate the allegations as the CNA denied them and resigned.
A CNA verbally abused three residents during a night shift, and the incidents were not reported immediately as required by the facility's policy. The abuse included yelling, profanity, and derogatory remarks, causing distress to the residents. The CNA continued to work the entire shift, as the incidents were only reported to the DON at the end of the shift.
A resident in a facility was subjected to ongoing verbal abuse, including racial slurs, by another resident. Despite initial reporting, the facility failed to implement effective interventions to prevent further abuse, resulting in continued distress for the victim. The facility's policy on abuse investigation and reporting was not adequately followed, and key staff were unaware of the full extent of the abuse.
A facility failed to implement its abuse prevention policy after a resident used racial slurs against another resident. Despite a room change, the verbal abuse continued for weeks, causing distress to the victim. Staff were unaware of the full extent of the abuse, and no follow-up was conducted to assess the effectiveness of interventions.
A facility failed to prevent and investigate verbal abuse between two residents, resulting in continued racial slurs and emotional distress for the affected resident. Despite staff awareness of the abuse, no thorough investigation or effective interventions were implemented, and the abusive behavior persisted for weeks.
A resident with anxiety and substance use issues exhibited aggressive behaviors, including yelling and racial slurs, but the facility failed to develop or update a care plan to address these needs. The resident was not referred to psychiatric services or a SUD Counselor, and staff interviews revealed a lack of coordination in care planning. Facility policies on behavioral assessment and substance use disorder were not followed.
A facility failed to provide adequate social services and behavioral interventions for two residents, leading to ongoing issues with aggressive behavior and verbal abuse. One resident, with a history of anxiety and substance dependence, exhibited disruptive behaviors without receiving a comprehensive care plan or appropriate referrals. Another resident was subjected to racial slurs and verbal abuse, with insufficient follow-up to ensure their well-being. The facility's lack of coordination and communication among staff contributed to these deficiencies.
The facility failed to accommodate residents' needs by keeping doors to a unit closed, making it difficult for wheelchair users to open them independently. Residents expressed frustration and fear of the doors closing on them. Additionally, the handicapped switches to the smoking area were not functioning, requiring residents to rely on others for access. Staff were unaware of the reasons for these issues, and no policy was in place to address residents' needs.
The facility failed to ensure a safe, clean, and homelike environment, with issues such as spills, improperly balanced tables, and maintenance deficiencies like clogged sinks and broken furniture. Staff interviews revealed reliance on a cloud-based system for maintenance requests, with no regular environmental rounds conducted.
The facility failed to develop and implement person-centered care plans for two residents with behavioral needs. One resident exhibited aggressive behaviors and alcohol intoxication, yet no behavioral interventions were implemented. Another resident, a veteran with combat experience, was inaccurately labeled as verbally abusive without proper assessment. The facility did not follow its policy on behavioral assessment and care planning, leading to deficiencies in addressing the residents' needs.
The facility failed to administer medications and provide care according to professional standards, affecting multiple residents. Medications were delayed or undocumented, including critical seizure and diabetic medications for a resident. Pain management and antibiotic administration were also mishandled, and care for urostomy and colostomy was not provided as ordered. An air mattress was used without a physician's order.
A facility failed to ensure a safe environment by not enforcing helmet use for a resident with cognitive impairments, allowing unsecured smoking materials for a resident with a legal guardian, and using portable heaters despite malfunctioning wall units. Staff interviews confirmed these deficiencies, highlighting a lack of policy enforcement and documentation.
The facility failed to develop trauma-informed care plans for four residents with histories of trauma, including a resident with a traumatic event, a veteran with combat injuries, a resident with a new amputation, and a resident with PTSD. Despite their histories, assessments and care plans were not completed, leaving potential triggers unaddressed.
The facility failed to ensure residents were seen by a physician at required intervals, as per CMS regulations. Seven residents were not seen every 30 days for the first 90 days after admission and at least every 60 days thereafter. Interviews with staff revealed a lack of awareness and oversight regarding physician visit scheduling and documentation, despite the physician being present in the building multiple times per week.
The facility failed to ensure that the binding Arbitration Agreement was explained to residents in a manner they could understand. Residents reported signing documents without understanding arbitration, and staff interviews revealed a lack of clarity and responsibility in explaining the agreement. The Administrator acknowledged the need for process revision.
The facility failed to maintain a QAPI Committee with required members present, as the Medical Director missed the last two quarterly meetings and the DON was absent from the last meeting. Despite claims of telephonic attendance and vacation, no documentation was provided to verify their participation.
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. A resident's respiratory equipment was not stored properly, another resident with chronic wounds and indwelling devices did not receive Enhanced Barrier Precautions, and a resident with MRSA was not under the correct Contact Precautions. Staff interviews confirmed the lack of proper procedures and signage for infection control.
A facility failed to report a verbal abuse incident where a resident used racial slurs against another resident. Both residents were cognitively intact, and the incident was not documented in the Health Care Facility Reporting System. The Director of Nurses and the Administrator were unaware of the racial slurs, leading to a failure to report the abuse to the Department of Public Health as required by policy.
A facility failed to complete a PASARR for a resident before their admission, as required. The PASARR was completed one day after the resident's admission. A social worker confirmed the oversight, and a corporate nurse noted the absence of a PASARR policy at the facility.
A facility failed to complete a baseline care plan within 48 hours for a resident with severe cognitive impairment and multiple diagnoses, due to inconsistent social service coverage and lack of regular meetings. The resident's Health Care Proxy was activated, but the representative did not receive the care plan.
A resident with complex medical conditions faced communication barriers due to the facility's failure to provide adequate language access services. Despite having a policy for language access, the facility did not inform the resident or their family about professional interpreting services, relying instead on staff with limited Spanish proficiency. This led to situations where the resident could not effectively communicate their needs, particularly regarding pain management and colostomy care.
A resident with hemiplegia following a stroke did not receive timely podiatry care, resulting in overgrown toenails and dry, flaky skin. Despite a physician's order for podiatry consultation as needed, the resident was not offered these services for a year. The facility's staff failed to identify and report the resident's foot condition during weekly skin assessments, leading to a deficiency in care.
The facility failed to maintain accurate records for controlled substances, as two residents' narcotic accountability records were not updated immediately after medication administration. A nurse admitted to administering Tramadol and Pregabalin without promptly documenting it in the Narcotic Book, leading to discrepancies in the medication count. The DON confirmed that narcotics should be signed out at the time of administration.
The facility did not maintain the main kitchen in a sanitary condition, with issues such as compromised floor grout and ceiling tiles. Observations revealed uneven and crumbling grout, debris, and standing water, particularly around key kitchen areas. Ceiling tiles were improperly fitted, with peeling and broken sections, and the metal grid showed black splotches. The FSD and DON acknowledged these deficiencies, noting the need for repairs to ensure cleanliness.
The facility failed to implement a comprehensive facility assessment, omitting input from direct care staff, residents, and family members. Social services did not create care plans for behavioral issues, despite a significant number of residents with behavioral health needs. The administration assumed social services were managing these concerns, but the assessment lacked necessary participant involvement.
The facility failed to notify the Ombudsman of resident transfers to the hospital, as required. Two residents, both cognitively intact, were transferred multiple times without the Ombudsman receiving the necessary notices. Interviews revealed that staff were unsure of the notification process, and the Director of Nurses was unaware of the oversight.
The facility failed to complete accurate MDS assessments for five residents, missing sections on pain, mental status, and mood. One resident with chronic pain and rheumatoid arthritis had an incomplete Pain Assessment Interview. Four other residents had incomplete BIMS and Mood Interviews, with sections marked as incomplete. The DON and MDS nurse acknowledged the lack of a specific MDS policy, relying on the RAI manual, and the Social Work Consultant was unsure why assessments were not completed.
A resident with dementia and anxiety disorder experienced an unwitnessed fall, resulting in a hematoma on the head. Despite new swelling and bruising on the resident's left hand being observed by two nurses on separate occasions, the NP was not notified until the resident complained of pain days later. This delay led to a late diagnosis of a wrist fracture, highlighting a failure in timely communication of changes in the resident's condition.
The facility failed to meet professional standards of quality in wound care management for four residents, leading to progression of wounds and inadequate treatment. One resident's non-pressure wound progressed to a Stage 3 pressure ulcer due to inaccurate transcription and implementation of treatment orders. Another resident's pressure ulcer treatment was not completed as ordered, and the treatment plan was not updated per the wound physician's recommendations. A third resident with a Stage 4 pressure ulcer experienced similar deficiencies, with inconsistent order transcription and lack of necessary supplies. These issues highlight significant gaps in wound care management and documentation.
The facility failed to provide proper wound care and monitoring for three residents, leading to deficiencies in managing their medical conditions. One resident's heel wound worsened due to delayed treatment, another's sacrum wound progressed to a Stage 3 ulcer due to incomplete treatments, and a third resident with CHF was not weighed weekly as required.
The facility failed to provide adequate care for pressure injuries for four residents, leading to deficiencies in wound management. A resident with a history of obesity and diabetes did not receive timely treatments, resulting in wound progression. Two residents with Stage 4 pressure injuries did not receive ordered treatments, and another resident with a Stage 3 ulcer lacked effective interventions. The facility did not adhere to its policies on pressure ulcer risk assessment and prevention.
The facility failed to maintain dignity and privacy for residents, including a resident with a visible Foley catheter without a privacy bag and another with a urinal left on their meal table. Additionally, misleading pest control signs were posted on doors of 16 residents' rooms, causing confusion. Staff interviews confirmed these practices did not meet the facility's expectations for resident dignity.
A resident experienced significant weight loss over several months due to the facility's failure to implement timely interventions. Despite recommendations from the RD to adjust the dosage of Remeron, an antidepressant used as an appetite stimulant, the facility did not act promptly. The resident's weight continued to decline, and weekly weight monitoring was delayed. Communication breakdowns and inconsistent follow-up by staff contributed to the deficiency.
A resident with a history of hypertension and atrial fibrillation was administered Carvedilol outside of prescribed parameters, despite a physician's order to withhold the medication if the heart rate was below 60 bpm. The Director of Nurses acknowledged the error, which occurred on multiple occasions in May 2024.
The facility failed to follow its food safety and sanitation policies, risking foodborne illness spread among residents. Observations in two kitchenettes revealed unlabeled, undated, and expired food items, as well as unclean equipment. Interviews confirmed dietary staff's responsibility for daily cleaning and proper storage, which was not adhered to.
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) policies, unsanitary handling of linens, and unclean medication storage areas. Staff did not adhere to EBP PPE requirements during wound care for residents with chronic wounds, despite attending training. These deficiencies highlight significant lapses in maintaining a safe and sanitary environment.
A resident with dementia continued to receive psychiatric services despite the Health Care Proxy's (HCP) decision to discontinue them. The facility lacked a signed consent form for these services, and the Psychiatric NP was aware of the HCP's refusal but continued providing services. The Director of Nurses confirmed the absence of consent and acknowledged that services should not have continued.
The facility failed to provide a dignified dining experience by playing loud music in a language not understood by residents and delaying meal service for some residents. Three residents had to wait 25 minutes for their meals due to a change in room assignments affecting the meal delivery schedule. Staff acknowledged the need for simultaneous meal service and appropriate music volume and language.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in care. One resident did not have their heels properly offloaded while in bed, contrary to the care plan's requirements. Another resident experienced delays in receiving assistance with toileting, despite the care plan's directive for prompt response. These failures highlight the facility's inability to adhere to essential care plan interventions, impacting the residents' health and safety.
The facility failed to maintain and store respiratory equipment safely for two residents. One resident's oxygen tubing was unlabeled, undated, and discolored, while another resident's nebulizer mask and tubing were not stored properly and were outdated. The facility's policy for changing and storing respiratory equipment weekly was not followed, leading to an infection control concern.
A facility failed to maintain monthly medication regimen reviews in the permanent medical record and did not address pharmacy consultant recommendations timely for a resident. The resident had an order for Lorazepam without a stop date, and the pharmacist recommended reassessment and consideration of discontinuation. However, the physician had not reviewed these recommendations for two months, and the reason for the delay was unclear.
A facility failed to limit the use of a PRN psychotropic medication for a resident with anxiety to 14 days or provide a documented rationale and duration for its continued use. Despite recommendations from the Consultant Pharmacist in April and May, the order for Lorazepam remained indefinite, and the recommendations were not addressed by a physician, as confirmed by the DON.
Failure to Protect Cognitively Impaired Residents From Non-Consensual Physical Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with severe cognitive impairment were treated with dignity and respect and protected from unwanted physical contact. Facility policy on Resident Rights, revised 1/2024, states that residents have the right to a dignified existence and to be treated with respect and dignity. Resident #1, admitted in October 2025 with diagnoses including psychotic disorder and Alzheimer’s disease, had a Quarterly MDS dated 1/23/26 indicating severely impaired cognitive patterns, and his/her health care proxy was activated on 1/19/26. Resident #2, admitted in December 2022 with unspecified dementia and psychotic disturbance, had an Annual MDS dated 11/14/25 showing severely impaired cognition and a court-appointed guardian as of 1/31/23. Resident #3, admitted in April 2025 with cerebral infarction and adjustment disorder with anxiety, had a Quarterly MDS dated 10/10/25 indicating severely impaired cognition and a court-appointed guardian as of 7/29/25. According to the Health Care Facility Reporting System, the facility reported multiple incidents in which Resident #1 initiated physical contact with Residents #2 and #3 without their consent. On 1/09/26, Resident #1 kissed Resident #3 and hugged Resident #2 without their consent. On 1/16/26, Resident #1 massaged Resident #3’s shoulders without consent. On 2/01/26, Resident #1 touched or groped Resident #2’s breast and groin area over clothing without consent. Social Workers #1 and #2 reported that they met with Resident #1 on 1/12/26 and 1/16/26 to discuss personal boundaries among residents; although Resident #1 verbalized understanding during these conversations, he/she appeared to forget the discussions and their content almost immediately afterward. During a telephone interview on 2/17/26, the Director of Nursing stated that Resident #2 was visibly upset and shaken following the incident in which Resident #1 touched his/her breast and groin area over clothing. These events demonstrate that the facility did not effectively prevent repeated, non-consensual physical contact between residents with severe cognitive impairment, resulting in a failure to uphold residents’ rights to dignity and respectful treatment.
Failure to Meet Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Obtain Informed Consent from Health Care Proxy for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the health care proxy (HCP) for a resident with dementia and depression was notified of the benefits, risks, and alternatives prior to the administration of a psychotropic medication. According to the facility's policy, written informed consent from the resident or their legally authorized representative is required before starting psychotropic medications. The resident in question had an HCP invoked and was prescribed Sertraline, an antidepressant, which was administered as ordered. A review of the resident's medical records, including both electronic and paper files, did not show any documentation that the HCP was informed about the medication's benefits, risks, or alternatives. Interviews with nursing staff and the unit manager confirmed that the required consent form was not present in the resident's record and that the HCP should have signed a consent form before the medication was initiated. The absence of this documentation indicates that the facility did not follow its own policy regarding informed consent for psychotropic medication administration.
Failure to Notify State PASRR Agency After Psychiatric Hospital Admissions
Penalty
Summary
The facility failed to notify the state agency responsible for Preadmission Screening and Resident Review (PASRR) following psychiatric hospital admissions for a resident with mental health diagnoses. According to facility policy and state regulations, a post-admission Level II PASRR evaluation (Resident Review) is required when a resident with or suspected of having a serious mental illness (SMI) is readmitted to the facility after an inpatient psychiatric stay. In this case, the resident had diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder, and was admitted to psychiatric hospitals on two occasions after their initial admission to the facility. Record review showed that the most recent PASRR for the resident was completed prior to these psychiatric hospitalizations. During an interview, the facility's social worker confirmed that no additional PASRRs were submitted after the resident's psychiatric admissions, despite being aware of the hospitalizations documented in the medical record. This lack of notification and failure to submit the required Resident Review in the PASRR portal constituted noncompliance with regulatory requirements.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Arrange Audiology Services for Resident with Hearing Loss
Penalty
Summary
The facility failed to arrange for an audiology appointment for a resident with a documented history of hearing loss. The resident was admitted with a diagnosis of hearing loss, and repeated Minimum Data Set (MDS) assessments over the course of a year documented moderate to highly impaired hearing, with no hearing aid or other hearing appliance in use. The resident's care plan identified communication problems related to hearing impairment, and interventions included discussing communication difficulties and administering ear drops for wax build-up. Despite a physician's order to consult audiology as needed and ongoing complaints from the resident about hearing difficulties, there was no evidence that an audiology referral was made. Interviews with staff and the resident's health care proxy revealed that the resident's hearing had worsened over the past year and that the issue was discussed in a care plan meeting. However, care plan meeting notes did not document the request for audiology services, and the medical records staff confirmed that no referral for audiology had been made, despite the audiologist visiting the facility quarterly. The resident was not included on the list for the most recent audiology visit, and staff turnover contributed to a lack of follow-through on the referral process.
Failure to Implement Updated Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a chronic stage 4 pressure ulcer received care and treatment in accordance with the wound consultant physician's orders. The resident, admitted with a stage 4 pressure ulcer on the ischium, had a care plan that included consultation and treatment by a wound physician, with specific orders for wound care. On multiple occasions, the wound consultant physician updated the treatment plan to include a collagen dressing in addition to antibacterial wound cleanser, Alginate, and foam dressing. However, review of the treatment administration records and physician's orders revealed that the updated order for the collagen dressing was not implemented in the electronic medical record or carried out by nursing staff. Interviews with nursing staff confirmed that the dressing changes performed did not include the collagen dressing as ordered by the wound consultant physician. The process for updating treatment orders after wound rounds was not followed, resulting in the resident not receiving the prescribed wound care. The deficiency was identified through review of medical records, treatment administration records, and staff interviews, which demonstrated a failure to implement and document the updated wound care orders for the resident's stage 4 pressure ulcer.
Verbal Abuse by CNAs During Night Shift
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff members during the night shift. The incident involved two Certified Nurse Aides (CNAs) who yelled at and made insulting comments to a resident who was frequently incontinent and dependent on staff for care. The resident, who was alert and oriented, reported feeling upset, humiliated, and cried after the incident. The resident's medical history included anxiety disorder, depression, and post-traumatic stress disorder, and they required assistance with hygiene and bathing. The incident occurred when the resident was incontinent in bed, and the CNAs responded by yelling and making derogatory remarks. The resident was told to get out of bed and walk to the shower without being cleaned up first, and the verbal abuse continued during the shower. The resident's roommate corroborated the account, stating that the CNAs yelled and made derogatory comments about the resident's incontinence and dietary habits. Both CNAs initially denied the allegations but later accused each other of making the abusive statements. The facility's internal investigation and interviews with the CNAs revealed inconsistencies in their accounts, with each CNA blaming the other for the verbal abuse. Despite the CNAs' denials, the consistent statements from the resident and their roommate indicated that both CNAs were verbally abusive. The facility's Director of Nursing and Administrator acknowledged the incident and the subsequent investigation, which led to the termination of the CNAs involved.
Verbal and Mental Abuse by CNA During Night Shift
Penalty
Summary
The facility failed to protect three residents from verbal and mental abuse by a Certified Nurse Aide (CNA) during the night shift. The abuse was witnessed by two staff members who reported that the CNA yelled at, swore at, and berated the residents, causing them to become embarrassed, upset, and cry. One resident reported being afraid of the CNA. The facility's policy on abuse investigation and reporting defines verbal abuse as the use of disparaging and derogatory language towards residents, which the CNA violated. Resident #1, who was cognitively intact and dependent on staff for care, reported that the CNA yelled at them and made them cry. Witnesses confirmed that the CNA used inappropriate language and threatened to leave the resident on a bedpan for two hours. Resident #2, who had moderate cognitive impairment and respiratory issues, was also yelled at by the CNA, causing them to cry. Witnesses reported that the CNA made derogatory remarks about the resident's requests for assistance with their window. Resident #3, who was cognitively intact and dependent on staff, was denied juice by the CNA, who made derogatory comments about the resident's condition. Although Residents #2 and #3 did not recall the incidents, witness statements supported the occurrence of verbal and mental abuse. The Director of Nurses was informed of the incidents, and the CNA denied the allegations and resigned. The facility did not substantiate the allegations due to the CNA's denial.
Failure to Report and Address Verbal Abuse by CNA
Penalty
Summary
The facility failed to implement and follow its Abuse Policy, resulting in verbal and mental abuse of three residents by a Certified Nurse Aide (CNA) during a night shift. Nurse #1 witnessed the initial incident of verbal abuse by CNA #1 towards Resident #3 around 12:30 A.M. but did not report it immediately to facility management as required by the policy. Instead, Nurse #1 waited until the end of the shift, approximately six hours later, to report the incidents to the Director of Nurses (DON). This delay allowed CNA #1 to continue working the entire night shift, during which she verbally abused two additional residents, Residents #1 and #2. Resident #3, who was cognitively intact with a BIMS score of 13 out of 15, was denied juice by CNA #1, who yelled at the resident, using profanity and derogatory language. Resident #2, who had moderate cognitive impairment and was receiving hospice services, was also verbally abused by CNA #1, causing the resident to cry. Resident #1, who was alert and oriented with a BIMS score of 14 out of 15, was similarly subjected to verbal abuse and threats by CNA #1, which left the resident upset and in tears. The facility's policy required immediate reporting of any allegations of abuse and placing the suspected perpetrator on administrative leave pending investigation. However, Nurse #1 did not follow these procedures, and CNA #1 was not removed from the facility after the first incident. The DON confirmed that staff did not adhere to the facility's policy, as she was not informed of the incidents until the following morning, after the night shift had ended.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by another resident. The incident involved two residents who were both cognitively intact and receiving rehabilitation services. The abusive resident used racial slurs and derogatory language towards the victim, which was witnessed by staff. Despite the initial incident being reported, the facility did not implement effective interventions to prevent further abuse, resulting in the continuation of verbal abuse for three weeks. The facility's policy on abuse investigation and reporting was not adequately followed. Although the initial incident was reported to the nursing supervisor, the facility did not conduct a thorough investigation or develop a comprehensive plan to separate the residents and prevent further interactions. The abusive resident was moved to a room diagonally across the hall, but this measure was insufficient as the residents continued to encounter each other during communal activities and smoking breaks. Interviews with staff revealed a lack of awareness and communication regarding the ongoing verbal abuse. Key personnel, including the Administrator and the Director of Nursing, were not fully informed of the racial slurs used during the initial incident. The facility's failure to document the abusive behavior and implement a behavioral care plan for the abusive resident contributed to the persistence of the problem. The victim expressed feelings of distress and isolation, choosing to remain in their room to avoid further encounters.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse policy and procedures to prevent further verbal abuse between residents. Specifically, after staff witnessed a resident using racial slurs to verbally abuse another resident, the facility did not initiate effective interventions to prevent further abuse. This resulted in the verbal abuse continuing for three weeks, causing the affected resident to cry and express a desire to decrease socialization. The incident involved two residents who were both cognitively intact and admitted for short-term rehabilitation. The abusive resident had a history of using racial slurs and became aggressive when redirected. Despite a room change to separate the residents, the facility did not document any follow-up with the victim to assess the effectiveness of this intervention. Staff interviews revealed that the abusive behavior continued, with the abusive resident making derogatory comments during smoking breaks and communal activities. The Director of Nursing and other staff members were unaware of the extent of the racial slurs and verbal abuse until surveyors brought it to their attention. The facility's failure to investigate and report the verbal abuse, as well as the lack of additional interventions to keep the residents separated, contributed to the ongoing distress of the victimized resident. The facility's policy required thorough investigation and reporting of abuse allegations, but these procedures were not followed in this case.
Failure to Prevent and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to implement its policy and procedures to investigate and prevent further verbal abuse between residents. Specifically, after staff witnessed a resident using racial slurs to verbally abuse another resident, the facility did not conduct a thorough investigation or initiate effective interventions to prevent further abuse. This resulted in the verbal abuse continuing for three weeks, causing the affected resident to cry and express a desire to decrease socialization. The incident involved two residents who were both cognitively intact and admitted for short-term rehabilitation. The abusive resident had a history of using racial slurs and was previously moved to a different room after an altercation. However, the facility did not document any follow-up or interventions in the medical records of either resident. Staff interviews revealed that the abusive behavior was known to multiple staff members, but no comprehensive investigation or effective separation of the residents was implemented. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, the Director of Nursing and Administrator were unaware of the racial slurs until surveyors brought it to their attention. The only action taken was a room change for the abusive resident, which was insufficient to prevent further incidents. The lack of staff education and failure to keep the residents separated allowed the abuse to continue, impacting the affected resident's emotional well-being.
Failure to Address Behavioral and Substance Use Needs
Penalty
Summary
The facility failed to provide effective and appropriate treatment and services to a resident with anxiety, demonstrated behaviors, and active substance use. The resident, who was admitted with a new above-the-knee amputation, anxiety, and cannabis dependence, exhibited aggressive and inappropriate behaviors, including yelling, swearing, and using racial slurs. Despite these behaviors, the facility did not develop, implement, or update a care plan to address the resident's behavioral needs, including interventions for verbal abuse, intermittent explosive disorder, and substance use. The facility's policies on behavioral assessment and substance use disorder were not followed. The interdisciplinary team did not evaluate the resident's behavioral symptoms or develop a person-centered plan of care. The resident was not referred to psychiatric services or a Substance Use Disorder (SUD) Counselor, despite having consented to be seen by psychiatric services. The facility's staff, including social workers and nursing staff, failed to create or participate in care plans related to the resident's behavioral concerns. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's needs. The social workers did not participate in care planning for behavioral concerns, and there was confusion about the referral process for the SUD Counselor. The facility's Director of Nurses and Administrator acknowledged the deficiencies in care planning and the lack of interventions to separate the resident from others after incidents of aggression and racial slurs. The facility did not have a system in place to prioritize residents at risk for substance use relapse.
Failure to Provide Adequate Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide adequate social services to two residents, resulting in a deficiency in ensuring the highest practicable mental and psychological well-being. Resident #105, who was admitted with a history of anxiety and cannabis dependence, exhibited aggressive and inappropriate behaviors, including verbal abuse and substance use, which led to emergency room visits. Despite these incidents, the facility did not conduct a social service evaluation or develop a comprehensive care plan to address the resident's behavioral needs. The lack of intervention and monitoring allowed the resident's disruptive behavior to continue without appropriate management or referral to psychiatric or substance use disorder services. Resident #141, who was admitted for short-term rehabilitation, was subjected to verbal abuse and racial slurs by Resident #105. The facility's response to these incidents was inadequate, as there was no follow-up to assess the effectiveness of interventions, such as room changes, or to ensure the resident's emotional well-being. The medical record for Resident #141 did not document the incidents or any subsequent actions taken to address the resident's distress, leaving the resident vulnerable to further abuse. Interviews with facility staff revealed a lack of coordination and communication regarding the management of residents with behavioral issues and substance use disorders. Social workers were not actively involved in creating or participating in care plans for residents with behavioral concerns, and there was no clear process for referring residents to the Substance Use Disorder Counselor. This systemic failure contributed to the ongoing issues faced by both residents, highlighting deficiencies in the facility's approach to managing complex resident needs.
Facility Fails to Ensure Accessible Environment for Residents
Penalty
Summary
The facility failed to accommodate the needs of residents on one of its units by not ensuring that the physical environment was accessible. Specifically, the doors to the River 1 Unit were consistently closed, making it difficult for residents in wheelchairs to open them independently. Multiple observations were made of residents struggling to open these doors, with some resorting to kicking them open or relying on other residents or staff for assistance. The residents expressed frustration and concern during a Resident Group meeting, noting that the doors were always closed without a clear reason, and they feared the doors might close on them if they did not move quickly enough. Additionally, the facility did not maintain the handicapped switches for the doors leading to the smoking area in good repair. The surveyor observed that the handicapped buttons were not functioning, and the outside button was loose and tilting. Residents reported that the buttons had been broken for months, requiring them to rely on others to hold the door open. The Maintenance Director acknowledged that the outdoor button had been non-functional for over a year, and the issue was only addressed after the surveyor's inquiry. Interviews with staff, including the Director of Nurses and Corporate Nurse, revealed a lack of awareness regarding the reasons for keeping the Unit 1 doors closed and the non-functioning handicapped buttons. There was no infection control or safety rationale provided for the closed doors, and no facility policy was in place to address the accommodation of residents' needs. The deficiency highlights the facility's failure to ensure an accessible environment for residents with mobility issues, impacting their independence and quality of life.
Environmental Deficiencies in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. On several occasions, spills were observed on the floor in the second-floor dayroom/dining room, along with tables being improperly balanced with books and heaters missing top covers and showing rust spots. Additionally, an armoire door was found detached in one room, and several rooms had scratched armoire doors, broken drawers, and clogged or dripping sinks. These issues were observed over a series of days, indicating a lack of timely maintenance and repair. Interviews with facility staff revealed systemic issues in the maintenance request process. The Unit Manager indicated that maintenance requests were entered into a cloud-based system called TELS, but there was no physical maintenance book for the unit. The Maintenance Director admitted that the department did not conduct regular environmental rounds and relied on unit staff to report issues. Furthermore, the Maintenance Director was unaware of several reported issues, such as the clogged sinks and broken armoires, suggesting a communication breakdown in the reporting and addressing of maintenance needs.
Failure to Implement Person-Centered Care Plans for Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in addressing their behavioral needs. Resident #105, who was admitted in December 2024, exhibited behaviors such as yelling, swearing, throwing furniture, exposing themselves, and alcohol intoxication. Despite these incidents, the facility did not implement a care plan with behavioral interventions to address these behaviors. Interviews with staff revealed a lack of clarity on who was responsible for creating and implementing behavioral care plans, with social workers and nursing staff both indicating that the other was responsible. Resident #141, admitted in January 2025, was a veteran who had experienced combat. The facility failed to create a care plan that acknowledged the resident's military background and potential trauma. Instead, a generic behavioral care plan was implemented, which inaccurately labeled the resident as verbally abusive based on limited and unverified observations. Interviews with staff and the resident indicated that the resident had not exhibited any significant behavioral issues, and the care plan did not reflect the resident's actual needs or experiences. The facility's policy on behavioral assessment and care planning was not followed, as evidenced by the lack of individualized interventions and the failure to involve residents in their care planning. The interdisciplinary team did not adequately assess the severity and potential safety risks of the residents' behaviors, nor did they develop appropriate care plans to address these issues. This lack of proper care planning and intervention highlights a significant deficiency in the facility's ability to provide person-centered care for residents with behavioral health needs.
Medication and Care Administration Deficiencies
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice across multiple units and residents. On one unit, morning medications were not administered as per physician's orders, affecting several residents. Interviews revealed that the medications were given hours later than scheduled, and in some cases, not documented properly, leading to potential double dosing. The Director of Nursing (DON) acknowledged the issue but was unable to provide a clear reason for the delay or lack of documentation. Resident #136, who has epilepsy, hypothyroidism, and diabetes, experienced significant delays in receiving critical medications, including those for seizures and diabetes. The resident expressed distress over the late administration, which was confirmed by the Medication Administration Audit Report showing multiple instances of late medication administration. Despite the resident's medical history indicating the importance of timely medication, the facility failed to adhere to the prescribed schedule. Other residents, such as Resident #105, did not receive pain management medications as ordered, and there were discrepancies between the Controlled Substance Log and the Medication Administration Record (MAR). Resident #210's intravenous antibiotic was administered late, and Resident #457 did not receive urostomy and colostomy care as per physician's orders. Additionally, Resident #110 was using an air mattress without a physician's order or documentation in the care plan, indicating a lack of adherence to professional standards and facility policies.
Safety Hazards and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment for Resident #138, who was admitted with diagnoses including cerebral infarction and decompressive hemicraniectomy. The resident was required to wear a helmet at all times when unattended, as per physician's orders. However, observations during the survey revealed that the resident was frequently found without the helmet while unsupervised, with the helmet placed across the room. Interviews with staff confirmed that the resident sometimes removed the helmet, but there was no documentation indicating refusal or removal by the resident. Resident #123, who has severe cognitive impairment and a legal guardian, was found to have a cigarette lighter and cigarettes unsecured in their room. The facility's smoking policy requires smoking materials to be safely secured, especially since the resident's roommate uses oxygen. Despite this, the resident's smoking materials were observed in plain sight multiple times, and staff interviews revealed a lack of consistent enforcement of the smoking policy. The resident's legal guardian had not signed the smoking agreement, which was a requirement given the resident's incapacitation. The facility also failed to maintain a safe environment by allowing the use of portable space heaters, which are considered fire hazards. Observations noted portable heaters in resident areas, including a sitting room and a resident's room, due to malfunctioning wall unit heaters. Staff interviews confirmed the use of these heaters despite the facility's policy against them, and the Maintenance Director acknowledged the lack of a formal policy on electrical devices and fire safety. The wall unit heaters were not functioning properly, and replacements were delayed, leading to the continued use of unsafe portable heaters.
Failure to Implement Trauma-Informed Care Plans for Residents
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care for four residents. Resident #145, who had a history of a traumatic and violent event, was admitted with severe cognitive impairment. Despite this history, the medical record did not include a care plan addressing past trauma. The Social Worker acknowledged the resident's traumatic history but did not conduct a trauma assessment or develop a care plan. Resident #141, a veteran with a history of military combat and war injuries, was cognitively intact and took medication for nightmares. However, the Social Service Evaluation failed to recognize the resident's combat experience as traumatic, and no care plan was implemented to address potential triggers from military trauma. The Social Worker and Social Work Consultant acknowledged the oversight but did not ensure a care plan was initiated. Resident #105, who had a new above-the-knee amputation, exhibited behaviors such as yelling and swearing, but was not assessed for a history of trauma. The Social Worker confirmed that a social history and trauma assessment were not completed. Resident #77, diagnosed with PTSD, did not have a care plan for trauma-informed care or PTSD, and potential triggers were not identified. The Social Service Evaluation was completed three months after admission, and the Social Worker admitted that a care plan should have been developed.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as per the Centers for Medicare and Medicaid Services (CMS) regulations. Specifically, seven residents were not seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter. The facility's policy, revised in February 2020, mandates that the medical care of each resident is under the supervision of a licensed physician, who is responsible for performing timely medical assessments and visiting residents at appropriate intervals. However, the records for these residents showed significant lapses in physician visits, with some residents not being seen for over 196 days. Interviews with facility staff, including Unit Manager #4, Medical Record Staff #1, the Director of Nurses, and Corporate Nurse #1, revealed a lack of awareness and oversight regarding the scheduling and documentation of physician visits. The Director of Nurses and Corporate Nurse #1 acknowledged that physician visits should alternate with Nurse Practitioner visits every 60 days, but this was not consistently happening. The physician was reportedly present in the building multiple times per week, yet there was no documented evidence of visits for the affected residents, indicating a breakdown in communication and adherence to regulatory requirements.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement, included in the admission packet, was explained to residents and/or their representatives in a manner they could understand. This deficiency was identified for three residents who had signed arbitration agreements. During a Resident Group Meeting, attendees expressed that they did not understand what arbitration was and mentioned that they were asked to sign documents post-admission without receiving copies of what they signed. Interviews with the facility's staff revealed a lack of clarity and responsibility regarding who should explain the arbitration agreement to residents. The Administrator was uncertain about who was responsible for obtaining signatures on the arbitration agreement, indicating that either the Receptionist or nursing staff might be involved. The Receptionist confirmed that she had residents sign admission paperwork but admitted she did not understand arbitration and had not been trained to explain it. Residents reported signing multiple documents upon admission without any explanation of the arbitration process. The Administrator acknowledged that the current process was inadequate and needed revision to ensure residents are properly educated about what they are signing.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members present at their meetings. Specifically, the Medical Director did not attend the last two quarterly QAPI meetings, and the Director of Nurses (DON) was absent from the last QAPI meeting. The facility's policy, revised in June 2019, mandates that the QAPI Steering Committee must include the Medical Director, Administrator, DON, Pharmacist, Staff Development Coordinator, and Social Services, with the Medical Director's attendance required quarterly. During interviews, the Assistant Administrator mentioned that the Medical Director sometimes attended meetings telephonically and would fax a signed attendance sheet, but no such documentation was provided. The Assistant Administrator also noted that the DON might have been on vacation during the last meeting. Despite these explanations, the facility did not provide additional documentation to verify the Medical Director's or DON's attendance at the meetings, leading to the deficiency noted by the surveyors.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For one resident, the facility did not ensure that respiratory equipment was stored in a clean and sanitary condition when not in use. The resident's nasal cannula was observed hanging from a door handle and a hook, with the nasal prongs touching these surfaces. Interviews with staff revealed that there was no instruction given to the resident on how to properly store the oxygen tubing, and there was no facility policy for the care of respiratory equipment. Another deficiency involved a resident with chronic wounds and indwelling devices, who was at increased risk for infection. The staff failed to implement Enhanced Barrier Precautions (EBP) as required. Observations showed that a nurse performed tracheostomy care and repositioned the resident in bed with only gloves donned, despite the presence of a PPE bin and an EBP sign at the room entrance. Interviews with staff confirmed that the resident required EBP due to their medical conditions, and that gowns and gloves should have been worn during care activities. A third deficiency was noted for a resident being treated for a blood infection with a multi-drug resistant organism (MRSA). The facility failed to implement the correct Contact Precautions, as the sign posted at the resident's room entrance was for Enhanced Barrier Precautions instead. Observations showed that a nurse did not wear a gown while administering IV antibiotics, contrary to the requirements for Contact Precautions. Interviews with staff revealed that the incorrect signage was posted, and the proper precautions were not followed for the resident's MRSA infection.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse involving two residents. Resident #105, who was cognitively intact, used racial slurs against Resident #141, also cognitively intact, during an altercation. This incident was not reported to the State Survey Agency as required by the facility's policy on abuse investigating and reporting. The policy mandates that any suspected abuse must be reported to the Administrator and other officials in accordance with state law, and the results of investigations must be reported within five business days. Despite the facility's policy, the incident involving racial slurs was not documented in the Health Care Facility Reporting System for the relevant period. The Director of Nurses was unaware of the racial slurs used during the altercation, and the Administrator was not informed that the incident constituted verbal abuse that required reporting. Consequently, the facility did not fulfill its obligation to report the verbal abuse to the Department of Public Health, as stipulated by their policy and state regulations.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident prior to their admission. The resident was admitted in December 2023, but the PASARR was not completed until one day after admission. During an interview, a social worker confirmed that the PASARR should have been completed before the resident's admission. Additionally, a corporate nurse revealed that the facility did not have a PASARR policy in place.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a resident was informed of and actively participated in their baseline care plan within the first 48 hours following admission. The facility's policy requires that a baseline care plan be developed within 48 hours of admission to meet the resident's immediate care needs. However, due to a lapse in consistent social service coverage, the baseline care plan for the resident was not completed. This lapse was confirmed during an interview with a social worker who indicated that the process involves initiating and completing the baseline care plan in the electronic health record, which did not occur for this resident. The resident in question was admitted with diagnoses of Parkinson's disease, Type II diabetes, and delusional disorders, and had a severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status assessment. The resident's Health Care Proxy was activated, but the representative did not receive a copy of the baseline care plan due to the absence of regular meetings where such plans are typically provided. A social work consultant, who began working with the facility after the deficiency occurred, acknowledged that meetings were not being conducted regularly, which contributed to the failure to complete the baseline care plan for the resident.
Failure to Provide Language Access Services for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practical well-being for a resident who primarily spoke Spanish. The deficiency was identified in the facility's inability to develop and implement an effective interdisciplinary care plan that addressed the resident's communication needs. Despite the facility's policy on providing language access services, the resident and their family were not informed about the availability of professional interpreting services, and the facility relied on staff with limited Spanish proficiency or family members for translation. The resident, who was admitted with complex medical conditions including acute polynephritis, severe sepsis, and a colostomy, experienced significant communication barriers. The resident's son, who was fluent in both English and Spanish, reported that upon admission, the facility did not discuss or offer professional interpreting services. Instead, the facility relied on staff who spoke some Spanish or Portuguese, which was insufficient for effective communication. This lack of proper communication led to situations where the resident was unable to understand staff responses, particularly regarding pain management and colostomy care. Interviews with various staff members revealed a lack of awareness and training regarding the use of telephonic interpreter services, which were available but not utilized. Staff members, including nurses and social workers, admitted to using gestures or calling family members to assist with translation, rather than using professional services. The facility's failure to ensure staff were trained and competent in providing language access services contributed to the resident's discomfort and inability to effectively communicate their needs, highlighting a significant deficiency in the facility's care provision.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with a diagnosis of hemiplegia following a stroke, who was admitted in December 2023. The resident, who had moderate cognitive impairment, expressed a desire to have their toenails and feet examined, as they had not seen a podiatrist since admission. Observations revealed that the resident had long, overgrown toenails that curled off the toes and dry, flaky skin on the feet. Despite a physician's order to consult with a podiatrist as needed, there was no record of the resident being offered podiatry services in the year since their admission. The facility's Unit Manager acknowledged that the resident's feet should have been checked as part of the weekly skin assessment, and the condition of the toenails and skin should have been noted and reported. The Director of Nurses confirmed that the nursing staff should have identified and reported the resident's foot condition to ensure timely podiatry care. The deficiency was identified when the resident was finally seen by a podiatrist, who documented elongated, discolored, and thickened toenails, along with dry, flaky skin on the feet.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain accurate drug records and account for all controlled substances, as observed during a survey. Specifically, the facility did not ensure that the narcotic accountability record was updated immediately after the administration of controlled substances for two residents. For one resident, a discrepancy was found between the number of Tramadol tablets documented in the Narcotic Book and the actual count in the medication cart. The resident had been administered a dose of Tramadol, but the administration was not recorded in the Narcotic Book at the time of administration, as confirmed by the nurse responsible. Similarly, for another resident, a discrepancy was noted with Pregabalin capsules, where the Narcotic Book showed one more capsule than was present in the medication cart. The nurse admitted to administering the medication but failing to document it in the Narcotic Book immediately. The Director of Nurses confirmed that all narcotics should be signed out of the Narcotic Book at the time of administration, not later. These lapses in documentation and accountability for controlled substances were identified as deficiencies during the survey.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. During observations on two separate occasions, the surveyor noted several issues in the main kitchen, including compromised and recessed floor grout. The grout was uneven, with some areas where the grout and tile were almost level and others where tiles protruded from the surrounding grout. Additionally, there were areas of crumbling grout, and crumbs, debris, and standing water were found in some of these recessed and crumbling areas. These issues were particularly noted around the steam table, food prep table, ice machine, and in the dish room. The ceiling in the main kitchen also presented several problems. The surveyor observed ceiling tiles that did not fit snugly within the metal ceiling grid, tiles with peeled layers protruding, and tiles with broken corners. The metal ceiling grid had surface areas with black, clustered splotches and peeling. During interviews, the Food Service Director acknowledged the issues with the grout and ceiling, attributing the ceiling problems to steam causing tiles to sag and black splotchy growth on the metal ceiling grids. The Director of Nursing also confirmed that the floor grout and ceiling tiles and gridding should be in good repair and easy to clean.
Incomplete Facility Assessment and Lack of Behavioral Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment to determine the necessary resources for providing competent care to residents during both routine operations and emergencies. The assessment, dated December 2024, was incomplete and did not actively involve all required members, such as direct care staff, residents, family members, and resident representatives. The facility's policy outlined the need for a detailed review of the resident population and available resources, but this was not adequately executed. Interviews revealed that the social services department did not participate in creating or implementing care plans related to behavioral concerns, despite the facility having a significant number of residents with behavioral health needs and substance use disorders. Social Worker #1 and Social Work Consultant #2 confirmed that social workers did not create care plans for behavioral issues, and the Director of Nurses was unaware of this gap in care planning. The Administrator also admitted that trauma-informed care and behavioral issues were not prioritized, assuming the social services department was managing these aspects. The facility assessment lacked input from essential participants, as sections for direct care staff, residents, family members, and staff representatives were left blank. The Assistant Administrator acknowledged that the assessment was completed with input from the administration team but did not include the required members. As of the survey's conclusion, no additional documentation was provided to demonstrate the involvement of these participants in the facility assessment process.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for the transfer of two residents to the hospital. Specifically, the facility did not send a copy of the Notice of Intent to Transfer Resident with Less than 30 Days' Notice to the Ombudsman's office. Resident #22, who was cognitively intact, was transferred to the hospital multiple times without the Ombudsman being notified. Similarly, Resident #46, also cognitively intact, was transferred to the hospital on several occasions without the Ombudsman receiving the required notices. The facility's policy on bed holds and transfers was not adhered to, as the Ombudsman was not informed of these transfers. Interviews with facility staff revealed a lack of understanding and execution of the notification process. Social Worker #1 admitted to not sending the necessary notices to the Ombudsman and was unsure of the correct procedure for completing and distributing transfer/discharge notices. The Director of Nurses was unaware that the notices were not being sent to the Ombudsman, indicating a breakdown in communication and procedure adherence within the facility. This deficiency highlights the facility's failure to comply with regulatory requirements for notifying the Ombudsman and resident representatives about resident transfers.
Incomplete MDS Assessments for Pain, Mental Status, and Mood
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were complete and accurate for five residents out of a sample of 33. For one resident, who was admitted with chronic pain syndrome and rheumatoid arthritis, the MDS assessment was incomplete as the Pain Assessment Interview section was not filled out. The Director of Nurses (DON) acknowledged the absence of a specific MDS policy, relying instead on the Long-Term Care Facility Resident Assessment Instrument user's manual. The MDS nurse admitted that the pain interview should have been completed but was not due to insufficient information in the resident's record. Additionally, for four other residents, the MDS assessments were incomplete in sections related to mental status and mood. The Brief Interview for Mental Status (BIMS) and Resident Mood Interview sections were marked with dashes, indicating incomplete assessments. The MDS nurse stated that these assessments should have been completed by social services, and if the residents were unable to participate, staff interviews should have been conducted. However, these assessments were not completed before the assessment review date. The Social Work Consultant confirmed that the assessments should have been completed and was unsure why they were not, indicating a lack of coordination in completing the necessary evaluations.
Delayed Notification of Provider Following Resident's Fall
Penalty
Summary
The facility failed to ensure timely notification of a resident's provider following a change in the resident's condition. Resident #1, who had a history of dementia and anxiety disorder, experienced an unwitnessed fall on 11/21/24 and was initially assessed with a hematoma on the left side of the head. The resident was sent to the hospital's emergency department for evaluation and returned to the facility without any noted wrist injuries. On 11/22/24, Nurse #3 observed new swelling and bruising on the resident's left hand but did not notify the nurse practitioner (NP) because the resident did not complain of pain. The following day, Nurse #2 noted the resident's refusal to use a walker due to left hand pain and observed swelling and bruising but did not notify the on-call provider due to uncertainty about whom to contact. It was not until 11/25/24, when the resident complained of wrist pain, that Nurse #3 contacted the NP, who then ordered an X-ray revealing a distal radial fracture. The Director of Nurses (DON) acknowledged that the nurses should have notified the NP or on-call provider upon noticing the changes in the resident's condition on 11/22/24 and 11/23/24. The delay in notification resulted in a late diagnosis and treatment of the resident's wrist fracture, which was only addressed after the NP was informed on 11/25/24.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to provide services that met professional standards of quality for four residents, resulting in significant deficiencies in wound care management. For one resident, the facility did not accurately transcribe and implement orders for changes in pressure and non-pressure wound treatments, leading to the progression of a non-pressure wound to a Stage 3 pressure ulcer. The resident had multiple wound sites, and the facility failed to complete the treatment ordered on numerous occasions. The facility's documentation and communication processes were inadequate, as evidenced by the lack of accurate transcription of wound care recommendations and the failure to notify physicians of changes in wound conditions. Another resident was admitted with a pressure ulcer to the coccyx and required specific wound care treatments. However, the facility did not complete the treatments as ordered on several occasions, and the treatment plan was not updated to reflect the wound physician's recommendations. The facility's failure to provide the prescribed treatments and to document the completion of treatments contributed to the resident's ongoing wound care issues. Interviews with nursing staff revealed a lack of awareness and accountability for ensuring that treatments were completed as ordered. A third resident with a Stage 4 pressure ulcer to the coccyx also experienced deficiencies in wound care management. The facility did not implement the recommended treatment plan, and there were inconsistencies in the transcription of orders. The facility ran out of necessary wound care supplies, and the treatment plan was not adjusted in a timely manner. The nursing staff failed to document the completion of treatments, and there was a lack of communication and coordination between the wound physician and the facility's nursing staff. These deficiencies highlight significant gaps in the facility's wound care management and documentation processes.
Deficiencies in Wound Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care for three residents, leading to deficiencies in managing their medical conditions. For one resident, the facility did not implement the Wound Consultant's recommendations for treating a non-pressure right heel wound. Despite the wound being identified and recommendations made, there was a significant delay in updating the treatment orders, resulting in the wound's condition worsening before appropriate care was administered. The resident's wound was not treated with the recommended collagen sheet with silver, and there was a lack of documentation and communication regarding the wound's status and treatment plan. Another resident experienced a progression of a non-pressure wound on the sacrum to a Stage 3 pressure ulcer due to the facility's failure to implement and complete treatments as ordered. The facility did not follow the Wound Care Physician's recommendations promptly, and there were multiple instances where treatments were not signed off as administered. The resident's medical record lacked documentation of physician notifications or reasons for not following the wound care recommendations, contributing to the deterioration of the wound. Additionally, the facility failed to ensure weekly weights were obtained for a resident with congestive heart failure, which is crucial for managing the condition. The lack of consistent weight monitoring could have impacted the resident's care and management of their heart condition. Overall, the facility's inaction and failure to adhere to treatment plans and recommendations led to significant deficiencies in the care provided to these residents.
Deficiencies in Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment for pressure injuries for four residents, leading to deficiencies in wound management and healing. Resident #4, who had a history of morbid obesity, diabetes, and peripheral vascular disease, was not provided with the necessary treatments for multiple pressure wounds. The facility did not implement the wound physician's recommendations in a timely manner, resulting in the progression of wounds from Stage 2 to Stage 3. The treatment administration records showed multiple instances where treatments were not signed off as administered, indicating a lack of adherence to prescribed care plans. Resident #2 and Resident #110 both had Stage 4 pressure injuries to the coccyx, and the facility failed to implement and complete the treatments as ordered. The wound physician's recommendations were not addressed promptly, and there was no documentation indicating that the physician declined these recommendations. This lack of timely intervention and documentation contributed to the residents' wounds not progressing towards healing. Resident #117 had a Stage 3 pressure ulcer on the coccyx, and the facility did not implement effective pressure-relieving interventions. The treatment administration records showed that treatments were not consistently signed off as administered, and the facility failed to follow the wound physician's recommendations. The facility's policies on pressure ulcer risk assessment and prevention were not adequately followed, leading to the deficiencies observed during the survey.
Dignity and Privacy Concerns in Resident Care
Penalty
Summary
The facility failed to maintain a dignified existence for two residents and 16 residents in one unit hallway. Resident #64, who was admitted with obstructive and reflex uropathy and chronic kidney disease, was observed with a Foley catheter drainage bag visible from the hallway without a privacy bag, contrary to the facility's policy and physician's orders. Despite the Treatment Administration Record indicating compliance, observations showed that the catheter was not consistently kept in a privacy bag, as confirmed by the Unit Manager and Director of Nurses. Resident #128, admitted with chronic respiratory failure, bipolar disorder, and major depressive disorder, experienced a lack of dignity during meals. The resident's urinal was left on the overbed table next to their meal tray, which was observed during breakfast and lunch. Both the resident and their roommate expressed discomfort with this practice. The Unit Manager acknowledged the issue as a dignity concern, and the Director of Nurses confirmed that the expectation to maintain dignity during dining was not met. Additionally, 16 residents in one unit were affected by signs posted on their doors indicating pest control service, which were misleading as the pest control company had not sprayed the rooms. The signs were left up without specific dates or times, causing confusion. Interviews with staff, including a CNA, a nurse, the Director of Maintenance, and the Administrator, revealed a lack of coordination and communication regarding the pest control schedule, leading to unnecessary and undignified signage on resident doors.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement timely interventions after identifying significant weight loss in a resident, who experienced an unplanned weight loss of 5.23% in one month to 17.82% over six months. The facility did not respond to the Registered Dietitian's (RD) recommendation to decrease the dose of Remeron, an antidepressant used as an appetite stimulant, from 22.5 mg to 7.5 mg. Additionally, the facility did not consider additional weight monitoring or interventions to curb further weight loss, resulting in continued significant weight loss over seven months. The resident, admitted with diagnoses including Parkinson's disease, muscle weakness, anorexia, and major depressive disorder, was cognitively intact and required assistance with meals. Despite the RD's repeated recommendations to adjust the Remeron dosage, the facility failed to address this recommendation timely. The resident's weight continued to decline, with significant weight loss documented from October 2023 to May 2024. The facility's policy required weekly weights for residents with significant weight changes, but this was not implemented until April 2024, three months after the significant weight loss should have been identified. Interviews with staff revealed communication breakdowns and inconsistencies in following up on the RD's recommendations. The Unit Manager acknowledged the delay in addressing the RD's recommendation and the lack of follow-up with the psychiatric nurse practitioner (NP) and RD. The facility had multiple dietitians filling in, leading to inconsistent follow-up. The psychiatric NP was not informed of the rationale behind the RD's recommendation, resulting in further delays in addressing the resident's weight loss.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of a beta blocker, Carvedilol, which was prescribed to manage the resident's paroxysmal ventricular tachycardia. The resident, who had a history of hypertension and atrial fibrillation, was supposed to receive Carvedilol twice daily, with the instruction to hold the medication if the heart rate was below 60 beats per minute. However, the Medication Administration Record (MAR) for May 2024 showed that the medication was administered on multiple occasions when the resident's heart rate was below the prescribed threshold. The Director of Nurses confirmed during an interview that the Carvedilol should have been withheld when the heart rate was less than 60, indicating that the physician's order was not followed. This oversight occurred on several dates in May 2024, with the resident's heart rate recorded as low as 55 beats per minute at the time of administration. This failure to adhere to the prescribed parameters constitutes a significant medication error, as the facility did not ensure the resident's medication was administered according to the physician's orders.
Food Safety and Sanitation Deficiencies in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to its policy and professional standards for food safety and sanitation, which could potentially lead to the spread of foodborne illness among high-risk residents. Observations revealed that in two of the four nourishment kitchenettes, food products were not properly labeled and dated, and equipment was not maintained in a clean and safe condition. Specifically, in the [NAME] Two Unit Kitchenette, the freezer contained food splatter, debris, and strands of hair, while the refrigerator held opened cartons of almond milk and a container of orange juice, both past their expiration dates. In the Riverside Two Unit Kitchenette, a sandwich and a bottle of Gatorade were found in the freezer without any date or resident identification labels. Additionally, a box of spoons and a container of plastic silverware were improperly stored under the sink, near plumbing piping, which poses a contamination risk. Interviews with the Regional Food Service Director confirmed that dietary staff are responsible for daily cleaning and stocking of the kitchenettes, including the removal of unlabeled, undated, or expired food items, and that nothing should be stored under the sink.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an infection prevention and control program effectively, as evidenced by several deficiencies observed during the survey. Firstly, the facility did not develop and implement policies and procedures for Enhanced Barrier Precautions (EBP) by the required date. The Director of Clinical Operations and the Infection Preventionist (IP) acknowledged that the EBP policy was not yet available, and the process was not fully implemented. Despite identifying residents who required EBP, the facility had not placed any residents on EBP due to the lack of a policy and necessary supplies. Additionally, the facility failed to handle linens in a sanitary manner in the laundry room. Observations revealed that laundry personnel dropped clean linens on the floor and attempted to use them without re-washing. The Laundry Manager and Regional Laundry Manager confirmed that the floor was considered dirty, and any linen that touched the floor should be rewashed. However, there was no specific policy provided to guide the staff on infection control practices in the laundry room. The facility also did not maintain clean medication storage areas, as observed in two medication rooms where cabinets contained a brown, splattered substance. Staff members, including nurses and the IP, acknowledged the unsanitary condition and the potential infection control concern. Furthermore, staff failed to adhere to EBP PPE requirements during wound care for residents with chronic wounds. Despite attending in-service training on EBP, staff did not wear protective gowns during high-contact care activities due to the unavailability of gowns. This non-compliance was observed during wound care for two residents with stage IV pressure ulcers.
Failure to Honor Resident's Right to Refuse Psychiatric Services
Penalty
Summary
The facility failed to honor the Health Care Proxy (HCP) of a resident, who had a diagnosis of dementia, by continuing to provide psychiatric services despite the HCP's explicit decision to discontinue such services. The resident had been admitted to the facility in November 2013 and had an activated HCP. The HCP expressed concerns about the facility billing for services that were not consented to and preferred the primary Nurse Practitioner (NP) to manage medication changes instead of the Psychiatric NP. Despite these preferences, the resident continued to receive psychiatric services from the contracted provider on multiple occasions. The facility's records did not include a signed consent form for the behavioral health services provided to the resident. The Psychiatric NP acknowledged awareness of the HCP's refusal of services and continued to provide them, citing a lack of clarity on the consent process. The Director of Nurses confirmed the absence of a consent form and stated that services should not have continued without it. The Behavioral Health Resident Log also indicated that the HCP did not want psychiatric services for the resident, yet the services persisted.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified and homelike dining experience for residents in one of its dining areas. During an observation, it was noted that loud dance music in a language not understood by the residents was playing, which was disruptive to the dining environment. Additionally, there was a delay in serving meals to some residents. Out of nine residents present, six were served their meals promptly, while three residents had to wait for their meals to arrive on a second lunch truck. This resulted in a 25-minute delay for the last resident to receive their meal. Interviews with staff revealed that the delay was due to a change in room assignments, which affected the meal delivery schedule. The Certified Nursing Assistant (CNA) and Unit Manager (UM) acknowledged that the residents should be served simultaneously to maintain a homelike atmosphere and that the music should be at an appropriate volume and language. The Food Service Director (FSD) confirmed that residents should not have to wait while others are eating and that all meal trays should arrive on the same truck to prevent such occurrences.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to implement interventions on the Comprehensive Care Plan for two residents, leading to deficiencies in care. For one resident, the facility did not properly offload heels while the resident was in bed, despite the care plan specifying that heels should be floating off the end of an off-loading pillow. Observations by the surveyor showed that the resident's heels were consistently resting directly on the pillow or the mattress, contrary to the care plan's requirements. Interviews with the resident and various staff members, including nurses and the Director of Nursing, confirmed that the heels should have been floating off the pillow, indicating a failure to adhere to the prescribed care plan. Another resident experienced delays in receiving assistance with toileting, which was a critical intervention outlined in their care plan to prevent falls and manage incontinence. The resident, who had moderate cognitive impairment and a history of falls, was observed requesting assistance multiple times without timely response from the staff. On one occasion, the resident waited 30 minutes for assistance after the surveyor requested help on their behalf. Interviews with staff, including nurses and the Unit Manager, acknowledged that such delays were unacceptable and not in line with the care plan's directive for prompt response to toileting requests. These deficiencies highlight the facility's failure to implement essential interventions as outlined in the residents' comprehensive care plans. The lack of adherence to the care plans resulted in inadequate pressure ulcer prevention for one resident and delayed toileting assistance for another, both of which are critical to the residents' health and safety. The observations and interviews conducted by the surveyor underscore the need for the facility to ensure that care plans are followed accurately to meet the residents' needs.
Failure to Maintain and Store Respiratory Equipment Safely
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a safe and sanitary manner for two residents. For one resident, the oxygen tubing was observed to be unlabeled, undated, and discolored, indicating it had not been changed as per the facility's policy. The nurse confirmed that the tubing should be labeled and dated weekly, and the unit manager acknowledged that the policy was not followed. The Director of Nurses also confirmed that the expectation for maintaining the oxygen tubing was not met. For another resident, the nebulizer mask and tubing were found sitting on the bedside table, not stored in a respiratory storage bag, and dated from several months prior. The resident was unsure if the staff had changed the tubing and mask recently. The unit manager and the Director of Nurses both confirmed that the policy for changing and storing the nebulizer equipment was not followed, as the equipment was old and not stored appropriately. The physician's orders for both residents indicated that the respiratory equipment should be changed and stored weekly, but the facility's records showed that these orders were not consistently followed. The Treatment Administration Record for the second resident showed that the weekly mask and tubing change was signed as completed, but the equipment was not changed as required, leading to an infection control concern.
Failure to Address Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were maintained as part of the permanent medical record and that recommendations made by the pharmacy consultant were addressed in a timely manner for a resident. The facility's policy required that resident-specific irregularities be documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate. Additionally, recommendations were to be acted upon and documented by the facility staff and/or the prescriber. However, for a resident admitted in September 2023, the medical record did not include the Consultant Pharmacist Recommendation to Prescriber forms for April and May 2024. The resident had a new order for Ativan (Lorazepam) to be administered every four hours as needed for anxiety, without a specified stop date. The pharmacist consultant made recommendations on two occasions, suggesting reassessment of the medication order and consideration of discontinuation or documentation of continued need with a specified stop date. Despite these recommendations, the Director of Nurses confirmed that the physician had not reviewed the pharmacy recommendations for April and May 2024, and the reason for this delay was unclear.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident using psychotropic medications on an as-needed (PRN) basis was limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. The facility's policy on psychotropic medication, revised in July 2023, requires that any continuation of PRN doses beyond 14 days must have the practitioner's documented rationale and specified duration in the order. However, for a resident admitted in September 2023 with a diagnosis of anxiety, a new order for Ativan (Lorazepam) was placed with an indefinite end date, violating this policy. The Consultant Pharmacist made recommendations to the prescriber on two occasions, in April and May 2024, to address the continued use of Lorazepam PRN without a specified duration. These recommendations highlighted the need for the prescriber to document their rationale and indicate the duration for the PRN order. Despite these recommendations, the forms were not signed by a physician, and the Director of Nurses confirmed that the recommendations had not been addressed by a physician, resulting in the continued indefinite use of Lorazepam without proper documentation.
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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