Fall River Jewish Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 538 Robeson Street, Fall River, Massachusetts 02720
- CMS Provider Number
- 225317
- Inspections on file
- 25
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fall River Jewish Home during CMS and state inspections, most recent first.
Two residents with PICC lines had dressings consisting of gauze covered by a transparent dressing that were not changed every two days as required by facility policy and professional standards. Nursing staff routinely changed the entire dressing every seven days, regardless of the presence of gauze, resulting in the dressings remaining in place longer than recommended for infection control.
The facility did not maintain adequate documentation or evidence of an active QAPI program, including the development, implementation, and evaluation of corrective actions or performance improvement activities. Despite policy requirements, meeting minutes and data analysis were missing for several months, and departmental reports lacked details on corrective actions or monitoring, resulting in a failure to address the full range of care and services.
The facility did not maintain proper documentation or evaluation of its QAPI program, specifically failing to develop and implement effective plans of action for ongoing resident concerns about food temperatures. Despite repeated complaints and observations of cold food delivery, there was no evidence of consistent monitoring, analysis, or corrective action to resolve the issue.
The facility did not maintain an effective infection prevention and control program for Legionella and other waterborne pathogens, as required by policy and CMS guidance. Despite a policy mandating quarterly flushing of the water system, there was no documentation that this had occurred, and the Director of Maintenance confirmed he had not performed or recorded any flushing during his tenure. Facility records and interviews further indicated a lack of evidence for completed control measures or a flushing schedule.
A resident with a history of heart conditions and intact cognition was repeatedly observed with multiple medications and nebulizer vials left at the bedside for self-administration, despite lacking a documented interdisciplinary team assessment or physician's order for all medications. Facility policy requires such assessments and orders, but only a limited assessment for two medications was found, and staff confirmed that proper procedures were not followed.
A resident with moderate cognitive impairment reported that a nurse threw a shopping bag at them and yelled, but the incident was handled only as a grievance without a formal investigation, suspension of the staff member, or required reporting to authorities, in violation of the facility's abuse prevention policies.
A resident with dementia and diabetes, who was moderately cognitively impaired, reported that a nurse threw a shopping bag at them and yelled, causing distress. The incident was documented as a grievance and addressed internally, but facility leadership did not report the potential abuse to authorities as required by policy, instead treating it as a customer service issue. The required external reporting was not completed until much later.
A resident with dementia and diabetes reported that a nurse threw a shopping bag at them and yelled, resulting in distress. The incident was documented as a grievance and addressed with an apology, but no formal abuse investigation or required documentation was completed, as the Administrator considered it a customer service issue rather than potential abuse.
A medication cart was observed to contain a large amount of loose pills and paper debris in several drawers, contrary to facility policy requiring safe, secure, and orderly storage of drugs and biologicals. Both a nurse and the DON confirmed the cart should be clean and free of debris, with cleaning expected weekly on the night shift, but this standard was not met.
Residents consistently received meals that were cold or lukewarm, with multiple reports and direct observations confirming that food was not maintained at safe and appetizing temperatures. Meals were sometimes left on open pushcarts for extended periods, and test trays showed food items below recommended temperatures. Staff practices, such as reconciling meal tickets on the unit, contributed to delays and further cooling of food, while the Food Service Director and Administrator were either aware of or surprised by the ongoing temperature issues.
Surveyors found that the facility failed to maintain sanitary conditions in the main kitchen and unit refrigerators, with observations of crumbling grout, peeling coving, and uncleaned spills and residues. These deficiencies were contrary to professional standards and the facility's own cleaning policies, as confirmed by interviews with the FSD and Administrator.
A resident was not provided with the required SNF ABN and NOMNC forms when Medicare Part A coverage ended, leaving them uninformed about the end of coverage and potential financial responsibility. Facility staff confirmed that the notices were not issued as required, and documentation could not be produced upon request.
The facility did not employ a qualified Food Service Director (FSD) as required. The current FSD lacked certification and had not registered for the necessary class, with experience limited to cooking roles and completion of a ServSafe course. The facility also did not have a full-time dietitian, with the current dietitian working only eight hours weekly. The Administrator was unaware of these deficiencies.
A surveyor observed multiple deficiencies in a LTC facility's kitchen, including unsanitary conditions, pest presence, and improper food handling practices. The facility served undercooked, unpasteurized eggs to residents and failed to label and date food items correctly. Staff did not adhere to proper hand hygiene and glove use, and food temperatures were not consistently checked before serving.
The facility failed to maintain an effective pest control program, resulting in small black flies in the kitchen and dining areas. Despite recommendations from the pest control contractor, sanitation issues such as food debris, standing water, and organic build-up were not adequately addressed. Residents reported gnats in dining and resident rooms, and surveyors observed flies in various areas. The Food Service Director acknowledged the need for improved cleaning practices.
A resident with a PICC line did not receive the required monitoring, flushing, and equipment changes as ordered. The MAR/TAR showed multiple instances where these tasks were not signed off as completed, and nursing progress notes did not document any refusal of treatment. Interviews with staff confirmed the failure to adhere to the prescribed care plan.
The facility failed to provide quality care for two residents by not implementing wound care treatments as recommended by the wound consultant. One resident's skin tear treatment was delayed and improperly managed, while another resident's vascular ulcer treatment was inconsistently applied, with preventative measures not implemented. Staff interviews revealed confusion about updating treatment orders, and the Assistant DON acknowledged the need for timely implementation of recommendations.
A surveyor found that medications in a LTC facility were not properly labeled with opening dates or resident names. This included Artificial Tears, Latanoprost, Levemir insulin, and Ketotifen, which were not labeled according to manufacturer's guidelines. Nurse #1 confirmed the labeling oversight, acknowledging the importance of labeling for proper medication management.
The facility failed to provide palatable and appropriately heated food to residents, as evidenced by resident complaints and test tray results. Residents reported receiving cold, mushy, and overcooked meals, with some items from the menu being unavailable. Observations during meal service showed that the plate warmer was not used, and beverages were left at room temperature. Test trays confirmed that food items were served at inadequate temperatures, validating the residents' complaints.
A facility failed to implement Enhanced Barrier Precautions (EBP) and ensure the use of Personal Protective Equipment (PPE) for a resident with a PICC line, a high-risk situation for MDRO transmission. Staff were observed not wearing required PPE during care activities, despite facility policy and signage indicating the need for gowns and gloves. Interviews revealed a lack of awareness and understanding of EBP requirements among staff, contributing to the deficiency.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inadequate monitoring and documentation of antibiotic use for several residents. Antibiotics were prescribed without proper documentation of symptoms or justification, and there was a lack of follow-up to determine the necessity of treatment. Interviews revealed systemic issues in communication and documentation, contributing to the deficiency.
A facility failed to include a resident's Health Care Proxy in care planning meetings for over a year, despite policy requirements. The breakdown occurred after the departure of the MDS nurse, leaving no process to invite residents or representatives to meetings. The Social Worker, consulting since December 2023, was not provided with necessary lists or documentation.
A resident's mail privacy was violated when a Receptionist at the facility opened their mail without consent, filled out a form, and returned it to an agency. The resident, who was cognitively intact and responsible for their own decisions, had not authorized the facility to open their mail. The Receptionist admitted to the mistake, unaware that the resident had not signed the authorization form. The Administrator confirmed the violation after a surveyor's inquiry.
A resident reported that their mail was opened and handled without consent by a facility receptionist, who completed and returned a form to an agency. Despite the resident's cognitive intactness and responsibility for their own decisions, the facility failed to document or follow up on the grievance, violating their grievance policy. The current administrator was unaware of the incident until a surveyor's inquiry.
A resident transferred to a facility with a check for $2,213.55 from their previous LTC, which bounced due to insufficient funds. The facility failed to report this potential misappropriation to the DPH within the required timeframe. Staff interviews revealed a lack of awareness about the issue, and the administrator acknowledged the oversight.
The facility failed to develop baseline care plans within 48 hours for two residents, one with mental health diagnoses and another admitted for short-term rehabilitation. The first resident did not have a care plan addressing mental health needs due to personnel changes and the absence of an MDS coordinator. The second resident, who was alert and oriented, did not receive a care plan summary and was confused about medications and goals, partly due to the inexperience and limited availability of social workers.
The facility failed to develop comprehensive care plans for two residents, including nutritional goals and interventions. One resident with dysphagia experienced significant weight loss, and although nutritional supplements were adjusted, no care plan was documented. Another resident with a history of bariatric surgery had no care plan addressing nutritional needs, despite following a specific diet. The Registered Dietitian was not creating care plans, as this was previously done by an MDS nurse who was no longer at the facility, and the Administrator was unaware of this gap.
A facility failed to limit the duration of PRN psychotropic medication for a resident admitted with anxiety and later to hospice care. The resident had an indefinite order for Lorazepam, contrary to CMS guidelines requiring a stop date. The facility's policy mandates a 14-day limit unless clinically justified, but the Director of Nurses was unaware of this requirement for hospice patients.
A resident with a history of bariatric surgery required a high protein diet, but the facility failed to accommodate this need. The resident had not seen the RD since admission, and there were no updates to their nutritional assessments or care plans. The resident reported weight gain and dissatisfaction with the diet. The RD and Food Service Director lacked communication, resulting in unmet dietary needs.
A resident with dysphagia was not provided with nectar thick liquids as ordered by the physician. Observations showed unthickened liquids served, and staff interviews revealed inconsistencies in the thickening process, including the use of improper measuring tools and lack of staff education on new thickener instructions.
The facility failed to inform three residents or their representatives about potential financial liability for non-covered services, as required by their policy on Medicare Denials-Advance Beneficiary Notice (ABN). The ABN forms lacked necessary financial information, and interviews revealed a lack of communication and responsibility among staff in ensuring the forms were properly completed.
A resident with Parkinson's disease was repeatedly treated in a degrading and insulting manner by a nurse, who called the resident lazy, questioned their need for assistance, and slammed a door in their face. The resident's account was corroborated by a family member and a CNA, leading to the nurse's suspension.
Failure to Change PICC Line Gauze Dressings per Standards
Penalty
Summary
The facility failed to provide care and maintenance of Peripherally Inserted Central Catheters (PICC) consistent with professional standards of practice for two residents who were receiving intravenous therapy. Both residents had PICC lines with a 2 cm x 2 cm split gauze placed over the insertion site, covered by a transparent dressing. Observations revealed that the dressings, which included gauze under the transparent dressing, were not changed according to facility policy and professional guidelines, which require gauze dressings to be changed at least every two days. For both residents, the transparent dressings with gauze underneath were observed to have been in place for more than two days without being changed. Interviews with the nurse responsible for changing the dressings confirmed that he routinely placed gauze over the insertion site before applying the transparent dressing and changed the entire dressing every seven days, regardless of the presence of gauze. This practice was in accordance with his understanding of facility policy, but did not align with the stated requirement to change gauze dressings every two days. The Regional Clinical Coordinator also confirmed that both residents had gauze under their transparent dressings and acknowledged, upon review of the facility policy, that the gauze dressings should have been changed every two days for infection control purposes. The failure to change the gauze dressings at the required frequency constituted a deviation from both facility policy and established infection control guidelines.
Failure to Maintain Documented QAPI Program and Performance Improvement Activities
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with adequate documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Although the facility's QAPI policy outlined a comprehensive process for addressing clinical care, quality measures, and other key areas, document review revealed that the QAPI manual lacked meeting minutes for several months and did not include evidence of corrective actions or monitoring for identified issues. Departmental reports listed potential concerns and activities, but there was no documentation of performance improvement projects (PIPs) being developed, implemented, or evaluated, except for a single mention of a food temperature project without follow-up data or outcomes. Interviews with the Administrator confirmed that while monthly QAPI meetings were reportedly held, there were no written records of discussions, goals, or data analysis for several months. The Administrator also indicated a lack of awareness regarding the requirement for ongoing PIPs. The QAPI manual contained lists of departmental activities and identified concerns, but these lacked details on corrective actions, monitoring, or evaluation of effectiveness, demonstrating a failure to address the full range of care and services, including clinical care, as required by the facility's own policy.
Failure to Maintain QAPI Program and Address Food Temperature Concerns
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with adequate documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility did not develop and implement appropriate plans of action in response to resident concerns regarding food temperatures. Although the QAPI policy required regular meetings, documentation, and monitoring of performance improvement projects, there were no meeting minutes for several months, and the QAPI manual lacked evidence of ongoing monitoring or evaluation of corrective actions related to food temperature issues. Residents repeatedly raised concerns about cold food being delivered to their rooms, and observations confirmed that some meals continued to be served from open push carts, which did not maintain food temperature. Despite the purchase of a new food truck, there was no documentation of audit results, goals for food temperature compliance, or evaluation of the effectiveness of corrective actions. The Administrator was unaware that open push carts were still in use, and the Food Service Director had not reported this as part of the QAPI process.
Failure to Implement and Document Water Management Controls for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program specifically related to the management of Legionella and other opportunistic waterborne pathogens in its water system. According to a review of facility policy and CMS guidance, the facility was required to conduct a risk assessment, implement a water management program with control measures such as flushing, and document these activities. However, documentation revealed that while the policy called for quarterly flushing of the water system, there was no evidence that this had been performed or recorded. The Director of Maintenance, who had been in the role for six months, confirmed that he had not conducted any water system flushing during his tenure and could not provide documentation of previous flushing activities. Further review of the facility's water management program materials, including schematics and diagrams, showed no reference to a flushing schedule or evidence of completed control measures. Interviews with both the Regional Director of Maintenance and the Director of Maintenance confirmed the lack of documentation and uncertainty about when, if ever, the water system was last flushed. As a result, the facility did not meet the requirements to implement and document control measures to prevent the growth and spread of Legionella and other waterborne pathogens.
Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident, admitted with a history of myocardial infarction and tachycardia and assessed as cognitively intact, was observed with multiple medications at their bedside. The resident reported that nursing staff would provide all their morning medications and leave them at the bedside, allowing the resident to sort and check the medications for accuracy before self-administering. Multiple observations confirmed the presence of various pills and nebulizer vials left within the resident's reach on several occasions. Facility policy requires that residents may only self-administer medications if the interdisciplinary care team, in conjunction with the attending physician, has determined and documented that the resident has the capacity to do so safely. The policy also mandates that such assessments be documented, that a physician's order be present, and that the resident's ability to self-administer be periodically re-evaluated. In this case, the resident's medical record did not contain a care plan or physician's order authorizing self-administration of all medications, nor was there documentation of an interdisciplinary team assessment for all medications, including the nebulizer. Interviews with facility staff confirmed that an assessment, physician's order, and care plan are required for self-administration of medications. The only available assessment was limited to Tylenol and Colace and did not include the resident's nebulizer or other medications. Despite this, staff continued to leave medications at the bedside, contrary to policy and without the necessary documentation or team assessment.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the investigation and reporting of abuse allegations for one resident. According to the facility's own policy, any complaint or suspicion of abuse is to be thoroughly investigated, the resident protected, the alleged perpetrator suspended, and the incident reported to the Department of Public Health and local law enforcement within two hours. However, when a resident with moderate cognitive impairment reported that a nurse threw a shopping bag at them and yelled, the incident was only addressed as a grievance. The Director of Social Services met with both parties, and the nurse apologized, but no formal investigation or documentation of interviews was completed, and the incident was not reported to the appropriate authorities at the time. The Administrator confirmed that the grievance was considered resolved without further investigation or reporting, as he did not view the incident as potential abuse but rather as a customer service issue. There was no evidence in the Health Care Facility Reporting System that the incident was reported as required by policy. The lack of immediate protection for the resident, failure to suspend the implicated staff member, and absence of a timely investigation and reporting process constituted a failure to follow established abuse prevention and response protocols.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report a potential allegation of abuse involving a resident with dementia and diabetes mellitus, who was assessed as having moderate cognitive impairment and was largely independent in activities of daily living. On the date in question, the resident reported to the Director of Social Services that a nurse entered their room, threw a shopping bag at them, and yelled at them, which left the resident upset and angry. The incident was documented as a grievance, and the Director of Social Services met with both the resident and the nurse, after which the nurse apologized. The grievance was signed by both the Director of Social Services and the Administrator on the same day. Despite the facility's policy requiring that any complaint, observation, or suspicion of abuse be thoroughly investigated and reported to the Department of Public Health and local law enforcement within two hours, there was no evidence that the incident was reported to the appropriate authorities at the time. The Administrator stated that he did not consider the incident to be abuse, viewing it instead as a customer service issue, and therefore did not report it as required. A review of the Health Care Facility Reporting System confirmed that no report was submitted for the incident until much later.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate a potential allegation of abuse involving a resident with dementia and diabetes mellitus, who was assessed as having moderate cognitive impairment but was independent in most activities of daily living. On the date in question, the resident reported to the Director of Social Services that a nurse entered their room, threw a shopping bag at them, and yelled, which left the resident upset and angry. The grievance was documented, and the Director of Social Services met with both the resident and the nurse, resulting in an apology from the nurse. The grievance form was signed by both the Director of Social Services and the Administrator. Despite the facility's policy requiring immediate and thorough investigation of any complaint, observation, or suspicion of abuse, including interviews and written statements from all involved parties, no further investigation or documentation was completed beyond the initial grievance form. The Administrator stated that he did not consider the incident to be potential abuse, viewing it instead as a customer service issue, and therefore did not suspend the nurse or initiate a formal investigation as outlined in facility policy.
Medication Cart Not Maintained in Clean and Orderly Condition
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a safe and secure manner, as required by policy. During an observation, one of two medication carts was found to contain a large amount of loose pills and paper debris in multiple drawers. The facility's policy states that drugs and biologicals must be stored in a safe, secure, and orderly manner, and that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary condition. Interviews with a nurse and the DON confirmed that the medication cart should be clean and free of loose pills and debris, and that cleaning was expected to occur weekly on the night shift, but the cart was not maintained as required.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported that their meals, including breakfast and lunch, were frequently served cold or lukewarm. Observations by surveyors confirmed that food trays were sometimes left on open pushcarts without insulation for extended periods before being served, resulting in significant drops in food temperature. Test trays prepared and served during the survey were found to have food items at temperatures below recommended levels, with items such as scrambled eggs and potatoes being lukewarm or barely warm. Residents repeatedly voiced concerns about cold food during food committee meetings and resident council meetings, and these concerns were corroborated by the Ombudsman. The surveyor observed that the facility used both enclosed meal trucks and open pushcarts for meal delivery, with the latter failing to maintain food temperature. Staff were seen reconciling meal tickets on the units, which delayed the delivery of trays and further contributed to food cooling. Despite ongoing resident complaints and acknowledgment by the Food Service Director that some food items were not warm enough, the issue persisted over multiple days and meals. The Administrator was unaware that open pushcarts were being used regularly for meal service, indicating a lack of oversight in meal delivery practices.
Deficient Sanitation and Maintenance in Kitchen and Unit Refrigerators
Penalty
Summary
The facility failed to maintain food service areas in accordance with professional standards for food safety and sanitation, as observed by surveyors. In the main kitchen, several areas of floor grout were found to be crumbling, deeply recessed, and covered with a gray, putty-like buildup. These compromised areas were particularly noted near the dish room, where the tile and grout were wet. Additionally, the kitchen had two different types of flooring, with raised vinyl flooring trapping crumbs and moisture at the juncture with ceramic tile. Floor and wall junctures throughout the kitchen had peeling or protruding coving, cracked and crumbling grout, and a missing door frame, all of which made cleaning difficult and did not meet the FDA Food Code requirements for easily cleanable surfaces. Surveyors also found that refrigerators in two unit kitchenettes were not maintained in a sanitary condition. In one kitchenette, there were pools of dried orange liquid under the crisper drawers, and in another, a resident's food bag was stuck to a sticky orange and red substance on the refrigerator shelf. The same sticky residue was observed on subsequent days, along with a milky white, crusted spillage in a crisper drawer containing food items. These observations indicated that spills and contamination were not being cleaned up in a timely manner, contrary to the facility's own policy requiring regular and as-needed cleaning of food service areas and equipment. Interviews with the Food Service Director and the Administrator confirmed that their expectations were for the kitchen floors, coving, and unit refrigerators to be kept in good repair and cleanable condition. However, the observed conditions did not align with these expectations or with the facility's cleaning and sanitation policy, which requires a comprehensive cleaning schedule and accountability for cleaning assignments. No specific residents were identified as being directly affected in the report, but the deficiencies were observed in areas serving all residents.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) to a resident whose Medicare Part A coverage was ending. The SNF ABN and NOMNC are mandated forms that inform residents or their representatives about the end of Medicare coverage, their right to an expedited review, and their potential financial liability if they choose to continue receiving services that may not be covered. In this case, the facility was unable to produce documentation that these notices were issued to the resident when their last covered day of Part A service occurred, despite the resident remaining in the facility after coverage ended. Interviews with facility staff revealed that the social service department was responsible for issuing these notices, but the previous social worker had not consistently provided them as required. The administrator acknowledged that the resident should have been informed about the end of coverage and potential out-of-pocket expenses. The current social worker, who was not employed at the time, confirmed that the resident should have received the ABN to be made aware of the estimated costs and reasons for non-coverage.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Food Service Director (FSD), as required by regulations. During an interview, the current FSD admitted to not being a certified food service manager and had not registered for the necessary certification class. The FSD's experience was limited to working as a cook at a local restaurant and hospital, and he had only completed the ServSafe Food Handler online course and exam. Additionally, the facility did not employ a full-time dietitian, and the current dietitian only worked eight hours a week. The Administrator was unaware of the FSD's lack of qualifications.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary condition, as observed by the surveyor. The kitchen floor was dirty with food particles, the floor tile grout had a black grimy build-up, and there was standing water in the dish rooms. Additionally, small black flies were present in various areas of the kitchen, indicating a pest problem. The Food Service Director (FSD) acknowledged the cleanliness issues and the presence of flies, stating that the floor required deeper cleaning and power washing. The facility also failed to ensure that residents were not served undercooked, unpasteurized shell eggs. The surveyor observed that the eggs used in the kitchen were not pasteurized, and several residents were served undercooked eggs. The FSD and the Administrator were under the impression that the eggs were pasteurized, but the facility's food delivery vendor confirmed that the eggs were unpasteurized. This oversight led to residents consuming potentially unsafe eggs. Furthermore, the facility did not ensure proper labeling and dating of food items in the main kitchen refrigerators. Numerous food items were found unlabeled and undated, some of which were past their safe consumption dates. Additionally, staff failed to practice proper hand hygiene and glove use, as observed by the surveyor. Staff members were seen handling food with contaminated gloves and not washing their hands appropriately. The facility also did not consistently check cooked food temperatures before serving, as required by their policy, leading to potential food safety risks.
Pest Control and Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of small black flies and sanitation concerns in the main kitchen and dining room. The facility's policy on pest control was not effectively followed, as there were no pest sightings recorded in the pest sighting log, despite multiple observations of flies by the pest control contractor and surveyors. The pest control contractor's reports indicated ongoing issues with drain flies and fruit flies in the kitchen, with recommendations for routine cleaning to deter fly breeding, which were not adequately addressed. The pest control contractor's visits revealed significant sanitation issues contributing to the pest problem, including heavy organic build-up in grout around drains, food debris on the kitchen floor, excessive moisture, and standing water in dishwashing areas. These conditions provided conducive breeding environments for flies. Despite recommendations to address these issues, such as cleaning and drying floors, fixing structural issues like baseboards, and maintaining a pest logbook, the facility failed to take effective action. During the survey, residents reported the presence of gnats in the dining room and resident rooms, and surveyors observed small black flies in various areas of the kitchen and dining room. The facility's Food Service Director acknowledged the sanitation issues and the need for better cleaning practices by the dietary staff. The pest control contractor confirmed that the fly issue persisted due to unresolved sanitation problems, emphasizing that the flies could only be eradicated if the kitchen sanitation was maintained and additional measures like fogging were implemented.
Deficiency in PICC Line Management and Documentation
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident, who was admitted with Alzheimer's dementia, chronic kidney disease, heart disease, and a urinary tract infection, required specific care for the PICC line, including monitoring, flushing, and changing the equipment. However, the facility did not implement these orders as required, leading to a deficiency in care. The review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the PICC line site was not monitored every shift as ordered, and the IV tubing was not changed every 24 hours. Additionally, the Sodium Chloride flush solution was not administered as required before and after antibiotic infusions. These tasks were not signed off as completed on multiple occasions, indicating a failure to adhere to the prescribed care plan. Interviews with consulting staff and the new Director of Nurses confirmed that the treatments should have been signed off as administered or completed, and there should not have been any unsigned boxes on the MAR/TAR. The nursing progress notes also failed to document any refusal of treatment by the resident, further highlighting the facility's failure to provide the necessary care and documentation for the resident's PICC line management.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide quality care according to the plan of care, facility protocols, and professional standards of practice for two residents. For the first resident, the facility did not ensure that wound care treatments were reflective of the recommendations from the physician wound consultant and aligned with the primary physician's treatment plan. The resident had a skin tear on the left shin, and the treatment plan was not updated in a timely manner to reflect the wound consultant's recommendations. The resident reported that the dressing was not changed as frequently as ordered, and an inappropriate adhesive bandage was used, causing the wound to bleed. For the second resident, the facility failed to implement wound care treatments and preventative recommendations from the physician wound consultant. The resident had a vascular ulcer on the left great toe, and the treatment orders were not consistently followed. The recommended use of lambswool between the toes was not implemented, and there were multiple instances where the prescribed treatments were not provided. The resident expressed concerns about the frequency of dressing changes, and observations confirmed that the dressings were not adequately maintained. Interviews with nursing staff revealed a lack of clarity regarding the process for updating treatment orders based on the wound consultant's recommendations. The Assistant Director of Nurses acknowledged that the treatment orders should have been followed and updated promptly. The primary physicians deferred to the wound consultant for treatment recommendations, but the facility did not ensure these were implemented effectively.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling of medications stored in one of the two medication carts, as observed by the surveyor on June 6, 2024. Specifically, the surveyor found that bottles of Artificial Tears for two residents were not labeled with the date they were opened. According to the manufacturer's instructions, these eye drops should be discarded 30 days after opening due to the potential breakdown of preservatives and bacterial growth. Additionally, a bottle of Latanoprost ophthalmic solution was not labeled with the resident's name, and a vial of Levemir insulin for another resident was not labeled with the date it was opened. The manufacturer's guidelines indicate that Levemir should be discarded 42 days after opening due to reduced effectiveness. Furthermore, a bottle of Ketotifen ophthalmic solution for another resident was also found without an opening date label. The manufacturer's instructions state that Ketotifen should be discarded 15 days after opening. During an interview, Nurse #1 acknowledged that eye medications should be labeled with the resident's name and expiration date to ensure proper disposal. Nurse #1 also admitted that the Levemir insulin should not be used as the opening date was unknown, highlighting a lapse in medication management and labeling practices within the facility.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food to residents that was palatable and served at appetizing temperatures, as evidenced by multiple resident complaints and test tray results. During a Resident Group Meeting, 14 residents expressed dissatisfaction with the food, describing it as mushy, overcooked, cold, and lacking fresh vegetables or fruit. Specific complaints included burnt eggs, cold food, and unavailability of items from the always available menu. Observations during meal service revealed that the plate warmer was not turned on, resulting in cold plates, and beverages were left at room temperature. Test trays confirmed that food items such as scrambled eggs, biscuits with sausage gravy, and puree meals were served at inadequate temperatures, with some items being cold and lacking flavor. Interviews with residents and staff further corroborated the issues with food quality and temperature. Residents reported consistently receiving cold meals, and staff acknowledged the deficiencies in food preparation and service. The surveyor's observations during breakfast and lunch services highlighted the facility's failure to maintain appropriate food temperatures, with items like chicken, mashed potatoes, broccoli, and drinks being served at tepid or room temperatures. These findings validated the residents' complaints and demonstrated the facility's inability to provide meals that meet the required standards for palatability and temperature.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and ensure the use of Personal Protective Equipment (PPE) for a resident with a peripherally inserted central catheter (PICC) line, which is considered a high-risk situation for the transmission of Multi-Drug Resistant Organisms (MDRO). The facility's policy requires the use of gowns and gloves during high-contact resident care activities for residents with indwelling medical devices, such as a PICC line. However, observations revealed that staff did not adhere to these precautions. On multiple occasions, staff members were observed not wearing the required PPE while providing care to the resident. For instance, a nurse was seen inspecting the PICC line dressing without wearing gloves or a gown. Additionally, certified nursing assistants (CNAs) were observed washing and dressing the resident without the appropriate PPE, despite the presence of signage indicating the need for such precautions. Interviews with staff members revealed a lack of awareness and understanding of the EBP requirements for residents with PICC lines. The deficiency was further highlighted during interviews with consulting staff and the Director of Nurses, who confirmed that the resident should have been on EBP due to the presence of the PICC line. The failure to implement and adhere to the facility's infection prevention and control program, as well as the lack of proper training and communication among staff, contributed to the deficiency in providing appropriate care for the resident.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, resulting in inadequate monitoring and documentation of antibiotic use for several residents. The facility's policy outlined the need for monitoring antibiotic use, training staff on antibiotic stewardship, and ensuring proper documentation when antibiotics are prescribed. However, the facility did not adhere to these guidelines, as evidenced by incomplete and inaccurate documentation in the line listing of infections for March, April, and May 2024. This included missing information on symptoms, culture results, and whether infections met the criteria for antibiotic treatment. Several residents were prescribed antibiotics without proper documentation of symptoms or justification for their use. For instance, one resident was given Azithromycin without any recorded symptoms or reasons for the prescription. Another resident was treated with Linezolid for a suspected UTI, but there was no documentation of symptoms or a culture to support the diagnosis. In multiple cases, antibiotics were prescribed based on minimal symptoms or without waiting for culture results, and there was a lack of follow-up to determine if the treatment was necessary. Interviews with facility staff and a physician revealed systemic issues in communication and documentation. Consulting staff admitted to not always obtaining or documenting culture results and follow-up conversations with providers. The physician expressed concerns about overprescribing antibiotics and the lack of adherence to stewardship guidelines, particularly with agency nurses and during off-hours. The facility's failure to document symptoms, culture results, and provider discussions contributed to the deficiency in antibiotic stewardship.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was provided the opportunity to participate in the care planning process, as required by their policy. The policy mandates that residents, their families, and/or legal representatives are encouraged to participate in the development and revisions of the care plan, with meetings scheduled at convenient times. However, the Health Care Proxy for a resident admitted in January 2021 reported not being invited to care plan meetings for about a year and a half, despite previously being included. Interviews revealed a breakdown in the care planning process. The Administrator indicated that care plans are initiated through the MDS process, but the Social Worker, who began consulting in December 2023, noted that since the departure of the previous MDS nurse in February, there had been no process in place to invite residents or their representatives to care plan meetings. The Social Worker was not provided with a list of residents or representatives to invite, nor could she find documentation indicating that the resident's representative was invited to the care plan meeting.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure the privacy of a resident's mail, resulting in a violation of the resident's rights. The resident, who was cognitively intact and responsible for their own financial and medical decisions, reported that the facility's Receptionist opened their mail without permission. The Receptionist filled out a form from the mail and returned it to a community agency without the resident's knowledge or consent. The resident had not authorized the facility to open their mail, as indicated by the unsigned form in the admission packet. The Receptionist admitted to opening the mail, stating it was an accident and that she was unaware the resident had not signed the authorization form. The mail was addressed to the resident, not the facility's business office. The Receptionist also mentioned the resident's financial situation, noting that the resident had not been paying the facility and had been spending their money on shopping. The Administrator, who was not in the position at the time of the incident, acknowledged the violation following the surveyor's inquiry.
Failure to Address Resident Grievance Regarding Mail Handling
Penalty
Summary
The facility failed to properly handle a grievance raised by a resident regarding the unauthorized opening and handling of their mail. The resident, who was cognitively intact and responsible for their own financial and medical decisions, reported that the facility's receptionist opened their mail, completed a form, and mailed it back to an agency without the resident's consent or knowledge. The resident expressed concerns to the facility's administrator in March 2024, but no follow-up or resolution was provided to the resident. The facility's grievance policy, last revised in December 2018, requires that grievances be documented and resolved with written decisions provided to the resident. However, the facility did not document the grievance or provide any follow-up to the resident. Interviews with the social worker and receptionist confirmed awareness of the incident, but no formal grievance or follow-up was recorded. The current administrator, who was not in position at the time of the incident, was unaware of any formal grievance or resolution efforts until the surveyor's inquiry.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report a potential misappropriation of funds to the Department of Public Health (DPH) within the required 24-hour timeframe, as mandated by federal guidelines. This deficiency involved a resident who transferred to the facility with a check from their previous long-term care facility, representing their personal funds amounting to $2,213.55. Upon attempting to deposit the check, it was returned due to insufficient funds, indicating that the resident never received their money. Despite the receptionist informing her superior and reaching out to Social Security, the issue remained unresolved, and the resident's funds were not recovered. Interviews with facility staff, including the administrator and a social worker, revealed a lack of awareness regarding the bounced check and the unresolved financial issue. The administrator, who started at the facility after the incident, acknowledged that the previous facility's failure to provide the resident with their money constituted misappropriation and should have been reported to the DPH. However, a review of the Health Care Facility Reporting System (HCFRS) showed no record of such a report being made, highlighting the facility's failure to comply with reporting requirements.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure immediate care needs are met. For one resident, who was admitted with mental health diagnoses including anxiety disorder, bipolar disorder, and schizoaffective disorder, the facility did not implement a baseline care plan to address these mental health needs. The resident had severe cognitive impairment and a court-appointed legal guardian, but the social worker did not complete the necessary care plan or provide a copy to the resident. The lapse in care planning was attributed to changes in personnel and the absence of an MDS coordinator. Another resident, admitted for short-term rehabilitation, did not receive a summary of the baseline care plan within 48 hours. The resident, who was alert and oriented, expressed confusion about their medications and goals for returning to the community. The resident reported not having an initial meeting with the interdisciplinary team within the required timeframe and was upset by the lack of communication. The social workers involved were either new to the facility or only available part-time, contributing to the failure to provide the necessary care plan documentation.
Failure to Develop Comprehensive Nutritional Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which included nutritional goals and interventions. Resident #40, who was admitted with dysphagia, experienced significant weight loss in March 2024. Although the Registered Dietitian increased the nutritional supplement MedPass to twice per day, there was no care plan documented to address the resident's nutritional status. The Registered Dietitian was unaware of who was responsible for creating or updating nutritional care plans, as the previous MDS nurse who handled this task was no longer at the facility. The Administrator confirmed that there was no current MDS nurse, and each department was responsible for their own care plans, but was unaware that the Registered Dietitian was not creating nutritional care plans. Resident #2, admitted with a history of bariatric surgery, was following a high protein, low carbohydrate diet and provided their own protein supplements. Despite this, there were no additional nutritional assessments or progress notes, and the care plans did not address the resident's nutritional needs. The Registered Dietitian had assessed the resident upon admission but did not create care plans with goals and interventions, as this was previously done by the MDS nurse. The Administrator acknowledged the absence of an MDS nurse and stated that unit nurses were creating nursing care plans, but was not aware that the Registered Dietitian was not involved in creating nutritional care plans.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that residents using PRN psychotropic medications were limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. This deficiency was identified for a resident who was admitted to the facility with a diagnosis of anxiety and later admitted to hospice care. The resident had a physician's order for Lorazepam to be administered as needed for anxiety, with an indefinite end date, which is against CMS guidelines that require a stop date for PRN psychotropic medications, even for hospice residents. The facility's policy on PRN psychotropic medications, issued in March 2018, states that such medications should not exceed 14 days unless necessary to treat a diagnosed specific condition documented in the clinical record. Despite this policy, the consultant pharmacist noted the lack of a specified stop date for the Lorazepam order during a medication regimen review. The Director of Nurses was unaware of the requirement for a stop date for hospice patients' psychotropic medications, indicating a gap in policy implementation and staff awareness.
Failure to Accommodate High Protein Diet for Resident
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident who had a history of bariatric surgery and required a high protein diet. Upon admission, the resident brought their own protein shakes but expressed concern about the cost of continuing to purchase them. The resident had not seen the Registered Dietitian since admission, and there were no additional nutritional assessments or progress notes in the medical record. The care plans for the resident did not address their specific nutritional needs, and the resident reported weight gain and dissatisfaction with the current diet provided by the facility. The Registered Dietitian acknowledged not having met with the resident since the initial assessment and was unaware of the resident's current dietary needs or the availability of high protein options at the facility. The Food Service Director confirmed that the resident had requested protein shakes, which he was unable to order, and admitted to not knowing which items would constitute a high protein diet. There was a lack of communication between the Food Service Director and the Registered Dietitian regarding the resident's dietary needs, leading to the deficiency in meeting the resident's nutritional requirements.
Failure to Provide Nectar Thick Liquids as Ordered
Penalty
Summary
The facility failed to ensure that Resident #40, who was diagnosed with dysphagia, received nectar thick liquids as ordered by the physician. During observations, it was noted that the resident was served unthickened coffee and apple juice for breakfast, contrary to the physician's order for nectar thick liquids. Interviews with staff revealed that the process for thickening liquids was not consistently followed, with CNA #1 admitting to not thickening the liquids before serving them to the resident. Additionally, there was confusion regarding the correct amount of thickener to use, as staff were using plastic disposable soup spoons instead of proper measuring spoons. Further investigation revealed that the facility had two different types of thickeners with different mixing instructions, leading to inconsistencies in preparation. The Sysco thickener directions differed from those of the Thick and Easy brand, and staff were not educated on the change in thickener or the new directions for use. The Assistant Director of Nurses acknowledged the lack of staff education regarding the new thickener and the absence of proper measuring tools, contributing to the improper preparation of thickened liquids for Resident #40.
Failure to Inform Residents of Financial Liability for Non-Covered Services
Penalty
Summary
The facility failed to inform three residents or their representatives about potential financial liability for non-covered services, as required by their policy on Medicare Denials-Advance Beneficiary Notice (ABN). The policy mandates that the ABN must include details of the care to be provided, the reason Medicare will not cover the services, and the estimated costs. However, upon review, it was found that the facility did not provide this information to the residents who had been taken off their Medicare Part A benefits. Interviews with facility staff revealed a lack of communication and responsibility in ensuring the ABN forms were properly completed. The Social Worker stated that she issues the ABN when informed of the need, but the forms lacked the necessary financial information. The Administrator acknowledged that the Executive Assistant was responsible for including the estimated cost per day on the ABN forms, but this was not done because the residents had alternative insurance. Despite this, the Administrator agreed that the cost should be identified for residents without insurance or those wishing to continue services. The Executive Assistant confirmed her role in providing the ABNs and acknowledged the omission of the estimated costs.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The Facility failed to ensure that a resident with Parkinson's disease was treated with dignity and respect. The resident, who was alert and oriented, required medication every two hours to manage symptoms related to the progressive brain disease. On multiple occasions, Nurse #1 spoke to the resident in a degrading and insulting manner, including calling the resident lazy and questioning their need for assistance. Nurse #1 also slammed a door in the resident's face when they approached the nursing station for medication. The resident reported these incidents to family members and staff, including the Assistant Director of Nursing (ADON) and the Social Worker. Family Member #1 corroborated the resident's account, stating that she overheard Nurse #1 telling the resident that they did not need assistance and belonged in an Assisted Living facility. Certified Nurse Aide (CNA) #1 also witnessed Nurse #1's disrespectful behavior, including calling the resident an addict and slamming the door in their face. Despite Nurse #1's denial of these actions, the consistent statements from the resident, family member, and CNA #1 indicate a pattern of disrespectful and degrading behavior. The Facility's internal investigation confirmed these findings, leading to the suspension of Nurse #1 pending further action. The Facility's failure to treat the resident with dignity and respect constitutes a significant deficiency in care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
