Fitchburg Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fitchburg, Massachusetts.
- Location
- 1199 John Fitch Hwy, Fitchburg, Massachusetts 01420
- CMS Provider Number
- 225216
- Inspections on file
- 21
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Fitchburg Healthcare during CMS and state inspections, most recent first.
A resident with severe dementia and a history of physical aggression was repeatedly involved in altercations with others due to inadequate supervision and ineffective interventions. Despite care plans and staff awareness of the resident's behaviors, the individual was left unsupervised in common areas, entered other residents' rooms, and engaged in aggressive acts, resulting in injuries and distress among residents. Staff interviews and direct observation confirmed lapses in supervision and the inability of current measures to prevent these incidents.
A CNA failed to treat a severely cognitively impaired resident with respect and dignity during incontinence care, using profanities and derogatory language in a loud tone. Multiple staff members overheard the inappropriate conduct, and the CNA admitted to using unprofessional language, violating facility policies on resident rights and dignity.
A facility failed to ensure accurate Advance Directives for a resident with declining cognitive status. Despite significant decreases in BIMS scores indicating severe cognitive impairment, the resident was not evaluated for decision-making capacity. Interviews revealed that the MDS Nurse did not inform the physician of the changes, and the Unit Manager acknowledged the oversight.
The facility failed to notify the physician of significant blood sugar changes for two residents with Diabetes Mellitus Type 2. Despite care plans and physician orders requiring notification for blood sugar levels above 400 mg/dL and below 70 mg/dL, the facility did not document such notifications. Interviews confirmed the lack of evidence for physician notification, acknowledging the oversight.
The facility failed to complete PASRR Level I screenings prior to admission for five residents with mental health diagnoses, including Dementia, Anxiety Disorder, and Major Depressive Disorder. The screenings were conducted only after admission, as confirmed by social workers, affecting residents admitted between May 2023 and January 2024.
The facility failed to ensure physician orders for a recommended HbA1c lab test for a resident on antipsychotic medication and did not maintain fluid restrictions or administer dietary supplements as ordered for a resident with ESRD. The facility lacked documentation and communication regarding the administration of a Nepro shake and fluid intake, leading to non-compliance with prescribed care.
A resident with severe cognitive impairment and mental health issues was not provided with a meaningful activity program aligned with their preferences. Despite expressing interest in activities like reading, music, and religious participation, the resident's care plan lacked interventions for these preferences. Observations showed the resident often without activities or personal items, and the Activity Participation Logs lacked evidence of offered or refused activities. The facility failed to ensure the resident's engagement in preferred activities.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter by not verifying the correct catheter size as ordered by the physician, leading to the use of a larger size that could cause trauma. Additionally, the facility did not arrange for a urology appointment as requested by the NP, despite the resident's diagnoses of benign prostatic hyperplasia and urinary retention.
A facility failed to maintain proper hydration care for a resident with CKD and HF, who was on a physician-ordered fluid restriction. The resident's fluid intake exceeded the prescribed limit on multiple occasions, with no documentation of communication with the physician. Interviews revealed a lack of written policy for monitoring fluid intake and output, and the dietitian was unaware of the excess intake until the survey.
A resident with chronic respiratory failure and heart failure did not receive the prescribed oxygen flow rate of 2 L/min as ordered by the physician. Observations showed the oxygen concentrator set at higher rates of 3 L/min and 3.5 L/min. The resident could not adjust the settings, and staff were unaware of the need for frequent checks, leading to a deficiency in respiratory care.
A facility failed to maintain ongoing communication with a dialysis center for a resident with ESRD, resulting in missing information on dialysis care and lack of follow-up on an elevated alkaline phosphatase level. Staff interviews revealed uncertainty about procedures when communication from the dialysis center was absent.
A facility failed to obtain physician orders for Vancomycin trough lab draws for a resident with MRSA and a kidney contusion. The resident was receiving Vancomycin intravenously, requiring troughs to be drawn twice weekly. However, the facility did not have documented physician orders for these lab draws on four occasions, as confirmed by the Unit Manager.
A resident with dysphagia experienced a delay in receiving a speech therapy evaluation after being identified as having difficulty swallowing. Despite a request for evaluation on the same day the issue was noted, the Speech Language Pathologist was not informed until much later, resulting in a significant delay in assessment. This failure to provide timely specialized rehabilitative services was contrary to the facility's policy and expectations.
A resident over the age of 65, who had previously received PCV-13 and PPSV23, consented to receive the PCV-20 vaccination upon admission. Despite the consent, the facility failed to offer or administer the PCV-20 within the expected timeframe, as confirmed by the Infection Preventionist, resulting in a deficiency.
The facility failed to accurately code MDS assessments for several residents, including not attempting required BIMS and PHQ-9 interviews for residents with dementia who were sometimes understood. Additionally, a resident's discharge was inaccurately coded, and another resident's pain medication was not documented in the MDS assessment.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and maintain a safe environment for a resident with severe cognitive impairment and a history of physical aggression on a secured dementia unit. The resident, diagnosed with Alzheimer's dementia and other behavioral disturbances, was involved in multiple resident-to-resident altercations, including physical and verbal incidents, despite documented behavioral care plans and interventions. The care plan noted the resident's tendencies to wander, enter other residents' rooms, and display aggressive behaviors, but interventions such as STOP sign banners and redirection were not consistently effective. Multiple reports submitted to the Health Care Facility Reporting System documented repeated incidents where the resident entered other residents' rooms, resulting in altercations and injuries, including lacerations and bruises. Staff interviews confirmed that the resident frequently removed STOP sign banners and entered rooms despite attempts to redirect or deter these behaviors. Staff also reported that the resident required two caregivers for personal care due to aggression and that there was no specific person assigned to supervise the resident when staff were occupied elsewhere. Direct observation by the surveyor revealed that the resident was left unsupervised in the dining/day room, which was not visible from the nurses' station and had areas not easily monitored by staff. During this time, the resident was seen pushing chairs, removing tablecloths, and approaching other residents without staff intervention. Interviews with staff and a psychiatric nurse practitioner confirmed that the resident should not have been left unsupervised, and that current interventions were insufficient to prevent further incidents, placing both the resident and others at risk for harm.
Failure to Ensure Respectful and Dignified Treatment During Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a severely cognitively impaired resident with respect and dignity during the provision of care. The resident, who had Lewy Body Dementia and PTSD, was admitted with severe cognitive impairment and a history of behavioral symptoms and rejection of care. During an episode of incontinence care, the CNA was overheard by multiple staff members yelling profanities and derogatory language at the resident in a loud and raised tone of voice while in the bathroom. Witnesses, including a nurse and another CNA, reported hearing the CNA use explicit language such as 'fucking dumb ass' and 'you fucking stand up' directed at the resident. The nurse responded by attempting to intervene, instructing the CNA to stop and exit the bathroom, but the CNA initially refused, citing the resident's unsafe position. Additional staff were summoned to assist, and the CNA eventually left the bathroom after repeated requests. The incident was reported to supervisory staff, including the shift supervisor and the DON, who confirmed through interviews and written statements that the CNA admitted to using inappropriate language and acknowledged her conduct was not respectful. The facility's policies on abuse investigation, reporting, and resident rights require all residents to be treated with respect and dignity. The CNA's actions, as directly observed and reported by staff, constituted a failure to uphold these standards, resulting in the resident being subjected to disrespectful and undignified treatment during care.
Failure to Evaluate Decision-Making Capacity After Cognitive Decline
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for a resident following a decline in their cognitive status. The resident, who was admitted with diagnoses including vascular dementia, cerebral infarction, and aphasia, showed a significant decline in cognitive function over several months, as evidenced by decreasing scores on the Brief Interview for Mental Status (BIMS) exam. Despite these changes, the facility did not evaluate the resident's capacity to make medical decisions, which is a requirement according to the facility's policy on Advance Directives. Interviews with facility staff revealed that the MDS Nurse was responsible for notifying the Unit Manager of any changes in a resident's cognitive status, who would then inform the physician to assess the resident's decision-making capacity. However, the MDS Nurse admitted to being unable to provide evidence that the physician had been informed of the resident's cognitive decline. Additionally, the Unit Manager acknowledged that a capacity evaluation should have been completed once the BIMS scores began to decline, but it was not done.
Failure to Notify Physician of Significant Blood Sugar Changes
Penalty
Summary
The facility failed to notify the Physician or Non-Physician Practitioner (NPP) of significant changes in the condition of two residents, both diagnosed with Diabetes Mellitus Type 2. For one resident, the staff did not inform the physician when blood sugar levels exceeded 400 mg/dL on multiple occasions, as required by the facility's diabetes management protocol. The resident's care plan and physician's orders specified that the physician should be contacted for blood sugar readings over 400 mg/dL, yet there was no documentation of such notifications in the nursing progress notes. Similarly, for another resident, the facility staff did not notify the physician when blood sugar levels were both below 70 mg/dL and above 400 mg/dL. The resident's care plan and physician's orders included specific instructions for notifying the physician under these circumstances. Despite these guidelines, the nursing progress notes lacked evidence of physician notification for these critical blood sugar readings. Interviews with the Nursing Regional Director of Operations confirmed that the facility could not provide evidence of physician notifications for the elevated and low blood sugar levels for both residents. The director acknowledged that the physician should have been informed of these significant changes in the residents' conditions, but this did not occur as required by the facility's policies.
Failure to Complete PASRR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission and Resident Review Level I (PASRR) screen was completed prior to admission for five residents out of a sample of 24. This screening is essential to assess for Serious Mental Illness (SMI) or Developmental Disabilities (DD) before a resident is admitted to a nursing facility. The deficiency was identified through interviews and record reviews, revealing that the PASRR Level I screens for these residents were completed only after their admission. Specifically, residents admitted with various mental health diagnoses, including Unspecified Dementia with behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, Schizoaffective Disorder, and Adjustment Disorder, did not have their PASRR Level I screens completed in a timely manner. Interviews with the facility's social workers confirmed that the PASRR screenings were conducted late, acknowledging that they should have been completed prior to the residents' admissions. This oversight affected residents admitted between May 2023 and January 2024.
Failure to Ensure Physician Orders and Fluid Restrictions
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents. For Resident #113, the facility did not ensure that physician orders were obtained for a recommended Hemoglobin A1C (HbA1c) lab test. This test was recommended by the Behavioral Health Nurse Practitioner due to the resident being on antipsychotic medication, which poses an additional risk for diabetes. Despite the recommendation, there was no documentation that the HbA1c lab was drawn, and the Minimum Data Set (MDS) Nurse confirmed that the lab was never conducted. For Resident #91, the facility failed to maintain and document fluid restrictions and administer dietary supplements as ordered by the physician for the treatment of End Stage Renal Disease (ESRD). The resident was on a renal diet with a specific fluid restriction and was supposed to receive a Nepro shake daily. However, the Medication Administration Record (MAR) indicated that the shake was not administered on multiple occasions when the resident was out of the facility. Additionally, the resident's fluid intake exceeded the prescribed restriction on several days, and there was a lack of communication between the facility and the dialysis center regarding the administration of the shake. Interviews with staff revealed gaps in the monitoring and documentation of fluid intake and the administration of dietary supplements. The Dietitian and Nurse #5 acknowledged the absence of a policy on fluid restriction and the lack of communication with the dialysis center. The Director of Nursing (DON) also noted the uncertainty about whether the Nepro shake was given at dialysis, as there was no documentation to confirm its administration or the amount consumed by the resident.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to implement a resident-centered, meaningful, and engaging activity program for a resident with severe cognitive impairment and multiple mental health diagnoses, including schizophrenia, dementia, major depressive disorder, and anxiety disorder. The resident expressed preferences for activities such as reading, listening to music, participating in religious activities, and going outside for fresh air. However, the resident's Activity Care Plan did not include interventions for musical activities or going outside, and there was no evidence that these preferences were offered or encouraged. Observations and interviews revealed that the resident was often left without any activities or personal items within reach. The resident was frequently found sitting in a chair facing a wall, with the television turned off and no reading materials or activity supplies available. Despite the resident's expressed interest in watching TV, the staff failed to ensure the TV was functional, and the remote controls were placed out of the resident's reach. The Activity Director acknowledged the lack of available activity materials and was unable to provide evidence that the resident had been offered or refused activities such as religious programs, musical activities, or reading materials. The Activity Participation Logs for August and September showed limited engagement in activities, with most interactions being brief verbal exchanges or independent TV activity. The logs did not document any offers or refusals of the resident's preferred activities, indicating a lack of adherence to the resident's care plan. The Activity Director admitted uncertainty about the resident's participation in religious programs and suggested that musical activities might have been offered, but there was no documentation to support this. The facility's failure to provide a resident-centered activity program resulted in the resident not participating in meaningful activities aligned with their preferences.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. Specifically, the staff did not verify the correct size of the catheter as ordered by the physician, resulting in the use of a size 18 Fr catheter instead of the prescribed 16 Fr. This discrepancy was observed by a surveyor, and the Unit Manager confirmed that the incorrect size was in place, acknowledging that increasing the catheter size could cause trauma to the resident. Additionally, the facility did not arrange for the resident to be seen by a urologist, as requested by the Nurse Practitioner, to prevent catheter-related complications. The Director of Nursing confirmed that the physician's orders regarding the catheter size were not followed and that the resident had not been seen by a urologist, despite the Nurse Practitioner's request. The resident, who was cognitively intact and dependent on activities of daily living, had been admitted with diagnoses including benign prostatic hyperplasia and urinary retention.
Failure to Monitor Fluid Restriction for Resident with CKD and HF
Penalty
Summary
The facility failed to maintain proper nutrition and hydration care for a resident with chronic kidney disease and heart failure, who was on a physician-ordered fluid restriction. The resident's care plan required a strict fluid intake limit of 1500 ml per day, divided among meals and medication passes. However, the facility did not adhere to this restriction, as evidenced by multiple instances where the resident's fluid intake exceeded the prescribed limit, reaching up to 2160 ml on one occasion. There was no documentation of communication with the physician regarding these excesses, indicating a lack of proper monitoring and adherence to the care plan. Interviews with facility staff revealed that there was no written policy for monitoring fluid intake and output or for managing fluid restrictions. The dietitian, who was responsible for overseeing the resident's fluid restriction in conjunction with nursing staff, was unaware of the excess fluid intake until it was pointed out during the survey. The dietitian acknowledged that staff might have provided extra fluids if the resident was thirsty but emphasized that any deviation from the fluid restriction should have been communicated to the physician. The facility failed to provide additional evidence or documentation of communication with the physician regarding the resident's fluid intake during the survey.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with a chronic pulmonary diagnosis. Specifically, the facility did not administer the appropriate liter per minute (LPM) of supplemental oxygen as ordered by the physician. The resident, who was admitted with chronic respiratory failure and heart failure, had a physician's order for oxygen administration at 2 L/min via nasal cannula. However, observations revealed that the oxygen concentrator was set at higher flow rates of 3 L/min and 3.5 L/min on multiple occasions. The resident, who had moderate cognitive impairment but retained the capacity to make medical decisions, was observed lying in bed with the nasal cannula in place. The oxygen concentrator was located at the head of the bed, out of the resident's reach, and the resident reported not being able to adjust the settings. Despite the physician's order, the oxygen flow rate was not routinely assessed or monitored to ensure it was set at the prescribed level. Interviews with the unit manager revealed that the staff was unaware of the resident's history of non-compliance with oxygen settings, and there was no specific order or care plan to check the oxygen flow rate more frequently. The facility did not provide additional information regarding the resident's oxygen administration to the survey team at the time of the survey exit.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure ongoing communication with a contracted dialysis center regarding the dialysis care and services for a resident with End Stage Renal Disease (ESRD). The resident, who was dependent on renal dialysis and had a history of atherosclerotic heart disease, was admitted to the facility with orders for hemodialysis three times a week. However, the facility did not maintain proper communication with the dialysis center, as evidenced by missing information in the dialysis communication book on several occasions. Specifically, there was no information from the dialysis center on the resident's care for multiple dates, and no follow-up communication was documented by the facility. Additionally, the facility did not address an elevated alkaline phosphatase level found in the resident's lab results. Although the lab result was flagged for the dietitian's review, there was no evidence of communication from the dialysis center regarding this elevated level, nor was there any follow-up from the facility after the resident's subsequent dialysis treatment. Interviews with facility staff revealed a lack of understanding of the procedures to follow when communication from the dialysis center was absent, further highlighting the deficiency in maintaining adequate communication and coordination of care for the resident.
Failure to Obtain Physician Orders for Lab Work
Penalty
Summary
The facility failed to ensure that physician orders were in place for lab work for a resident reviewed for infection control. Specifically, the facility did not obtain physician orders prior to completing Vancomycin trough laboratory draws for a resident who was admitted with a diagnosis of left kidney contusion and Methicillin Resistant Staphylococcus Aureus (MRSA) in the bloodstream. The resident was receiving Vancomycin intravenously as per the physician's orders, which required Vancomycin troughs to be drawn twice weekly. Upon review, it was found that the resident had Vancomycin trough labs drawn on four separate occasions without documented physician orders. The facility's policy indicated that the physician would identify and order diagnostic and lab testing based on the resident's needs. However, there was no documentation of physician orders for the Vancomycin trough labs drawn on the specified dates. During an interview, the Unit Manager confirmed the absence of physician orders for these lab draws.
Failure to Provide Timely Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide timely specialized rehabilitative services for a resident diagnosed with dysphagia, who was experiencing difficulty swallowing. The resident was admitted in February 2015 and had a documented history of swallowing issues. On September 6, 2024, nursing staff noted the resident's increased difficulty with mechanical soft meals and downgraded the diet to puree. A speech and language therapy evaluation was recommended by the Nurse Practitioner and requested by nursing staff on the same day. However, there was no documentation indicating that the resident had been evaluated by a Speech Language Pathologist (SLP) by September 26, 2024. Interviews conducted during the investigation revealed that the SLP was only made aware of the evaluation request on September 23, 2024, significantly later than the initial request date. The SLP stated that evaluations should be completed within a week of the request, and the Rehabilitation Services Regional Director of Operations confirmed that residents should be seen within a couple of days of an evaluation request. The delay in providing the necessary evaluation for the resident's swallowing difficulties constituted a failure to adhere to the facility's policy and expectations for timely rehabilitative services.
Failure to Administer Pneumococcal Vaccination Timely
Penalty
Summary
The facility failed to ensure the timely administration of the Pneumococcal Vaccination to a resident who had consented to receive it. The resident, who was over the age of 65, had previously received the PCV-13 and PPSV23 vaccinations. Upon admission in October 2023, the resident consented to receive the recommended Pneumococcal Vaccination, specifically the PCV-20, as per CDC guidelines. However, there was no documentation indicating that the PCV-20 was offered or administered to the resident, despite the consent being signed. The Infection Preventionist (IP) confirmed during an interview that the facility's policy is to offer Pneumococcal Vaccinations at the time of admission and as needed thereafter. The IP acknowledged that the resident had signed the consent form for the vaccination upon admission, and it should have been administered within a week. However, the IP was unable to find any documentation that the PCV-20 was offered to the resident, leading to the deficiency noted by the surveyors.
Inaccurate MDS Assessments and Missed Interviews
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the assessment process. For three residents, the facility did not attempt the Brief Interview of Mental Status (BIMS) and Patient Health Questionnaire-9 (PHQ-9) interviews, despite the residents being identified as at least sometimes understood. These residents had diagnoses including unspecified dementia with behavioral disturbance, and their MDS assessments indicated they were usually understood and had clear speech. The MDS Nurse confirmed that these interviews should have been attempted but were not. Additionally, the facility inaccurately coded a resident's discharge MDS assessment, indicating discharge to an acute care hospital when the resident was actually discharged to their home in the community. Another resident's MDS assessment failed to code the use of a prescribed medication for pain management, and the BIMS and PHQ-9 interviews were not completed, despite the resident having clear speech and being able to make themselves understood. The MDS Nurse acknowledged these oversights during interviews.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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