Fitchburg Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fitchburg, Massachusetts.
- Location
- 94 Summer Street, Fitchburg, Massachusetts 01420
- CMS Provider Number
- 225227
- Inspections on file
- 21
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fitchburg Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to implement physician orders and monitor residents, leading to significant deficiencies. A resident was hospitalized due to inadequate fluid restriction management, another did not receive necessary lab tests, and a third had incorrect air mattress settings. These failures highlight lapses in following medical directives and ensuring proper care.
The facility failed to notify the physician of critical lab results for a resident, leading to hospitalization for acute hypokalemia and acute kidney injury. Additionally, the facility did not obtain ordered labs for another resident with chronic kidney disease and heart failure, impacting their care. Interviews revealed lapses in communication and protocol adherence among nursing staff.
The facility failed to develop individualized care plans for residents with PTSD, suicidal ideation, and a cardiac pacemaker. A resident with PTSD had a non-specific care plan, while another lacked a PTSD care plan entirely. A resident with suicidal ideation had no care plan for monitoring mental well-being. Additionally, a resident with a pacemaker had an incomplete care plan, leading to staff confusion about its management.
A facility failed to properly execute an Advanced Directive for a resident. The MOLST form, indicating Do Not Resuscitate and Do Not Intubate orders, was signed by a nurse practitioner and an unauthorized individual, not the resident. The resident had moderately intact cognition and no invoked health care proxy, making the MOLST invalid.
A resident with COPD, chronic respiratory failure, and schizophrenia developed a fungal infection in the groin area, which was not reported to the physician by the facility staff. Despite the resident's complaints and attempts to self-treat, there was no physician's order for antifungal treatment, and the facility's documentation failed to reflect proper notification and treatment.
Two residents in a facility experienced deficiencies in care. One resident on anticoagulants had bruising that was not documented or reported to a physician, despite facility protocols requiring monitoring for such complications. Another resident reported a fungal infection in the groin, but the facility failed to obtain a treatment or notify a physician, despite weekly skin reviews noting antifungal powder application without a corresponding order. These issues reflect a lack of adherence to monitoring and documentation protocols.
A facility failed to conduct a smoking assessment and develop a care plan for a resident who resumed smoking after admission. Despite being listed as requiring supervised smoking, there was no Safe Smoking Evaluation or care plan in place. The resident, with several medical conditions, initially indicated no tobacco use but later resumed smoking without proper documentation or evaluation.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. A resident received oxygen at a higher rate than prescribed, another had expired oxygen tubing and incorrect oxygen settings, and a third lacked a physician's order for oxygen use. These issues were confirmed by staff interviews and observations.
A facility failed to ensure proper medication storage and administration for a resident, resulting in a deficiency. Medication was left unattended at the resident's bedside, contrary to facility policy requiring medications to be stored in locked compartments and administered under supervision. The resident, who was cognitively intact, had a prescription for calcium carbonate tablets, but no self-medication assessment was documented. Staff interviews confirmed the protocol breach.
A resident with hemiplegia and hemiparesis following a stroke experienced a delay in receiving occupational therapy (OT) services due to the facility's reliance on per diem OT staff, who were only available once a month. Despite a doctor's order for OT following complaints of pain and stiffness in the resident's left-hand joints, the evaluation was conducted nearly a month later, exceeding the facility's two-week expectation for therapy screens.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in oxygen therapy and wound care documentation. One resident received oxygen at a higher rate than ordered, while another had incorrect documentation regarding oxygen tubing changes and antifungal treatment. A third resident's wound dressing changes were inaccurately recorded. Staff interviews confirmed these discrepancies.
The facility failed to provide a safe and clean environment, with five resident rooms having baseboard heaters in disrepair and three shower rooms found dirty with mildew. A resident reported unclean conditions, and the Director of Environmental Services confirmed cleaning expectations were not met. The facility lacked policies for maintaining resident care areas, and the Administrator acknowledged unresolved issues with heater covers.
The facility failed to serve food at safe and appetizing temperatures on Unit A, with several food items found below the required temperature range during a test tray observation. Residents expressed dissatisfaction with the food quality, describing it as cold and lacking variety. The Food Service Director and Administrator acknowledged issues with maintaining food temperatures, citing equipment malfunctions and the absence of a pellet system.
The facility's main kitchen was found to be unsanitary, with fingerprints and smears on freezer and refrigerator doors, and missing protective pieces on freezer handles. Additionally, two cooks were observed handling food without wearing required hair restraints, violating the facility's hygiene policies. The Food Service Director acknowledged the need for a better cleaning schedule and confirmed that all dietary staff should wear hair coverings.
The facility failed to update the care plan for a resident at high risk for elopement after an incident where the resident attempted to leave the facility. Despite being redirected back, no new interventions were added. Another resident, also at high risk for elopement, did not have a care plan addressing this risk. The facility's policy required such plans, but they were not implemented.
A resident with moderate cognitive impairment and high elopement risk left the facility twice without staff knowledge. The first incident involved the resident being found in the parking lot, and the second incident resulted in the resident being found blocks away with bruises and abrasions. Despite the resident's care plan identifying elopement risk, no new interventions were added after the first incident.
Failure to Implement Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to meet professional standards of practice for three residents, leading to significant deficiencies in care. For Resident #44, the facility did not adequately assess, monitor, and implement a physician's order for fluid restrictions, which was crucial given the resident's chronic kidney disease and congestive heart failure. This oversight contributed to the resident's hospitalization with acute hypoxic respiratory failure, acute renal failure, and septic shock. Additionally, the facility did not follow up on a physician's recommendation for a new prosthetic leg, nor did it implement an order for a bilateral shoulder X-ray, leaving the resident without necessary evaluations and interventions. Resident #29 experienced a deficiency in care due to the facility's failure to obtain ordered laboratory tests. Despite a physician's order for weekly labs to monitor and adjust treatment for hyponatremia, the facility did not conduct these tests over several months. This lack of compliance with physician orders left the resident's condition unmonitored and potentially untreated, as the necessary lab results were not available to guide medical decisions. For Resident #1, the facility did not ensure that the air mattress was set according to the physician's order. Observations revealed that the mattress settings did not match the prescribed settings, which were intended to prevent skin issues. Despite documentation indicating compliance, the actual settings were incorrect, indicating a failure in the facility's processes to ensure adherence to physician orders and proper care for the resident's condition.
Failure to Notify Physician of Critical Lab Results and Obtain Ordered Labs
Penalty
Summary
The facility failed to notify the physician of critical laboratory results for two residents, leading to significant delays in treatment. Resident #12, who was admitted with dementia and chronic obstructive pulmonary disease, had critically high blood urea nitrogen (BUN) and critically low potassium levels reported on 2/26/25. Despite the lab's attempts to alert the facility, the results were not communicated to the physician until the following day, resulting in the resident being hospitalized for acute hypokalemia and acute kidney injury. Interviews revealed that the nursing staff did not follow the protocol for handling critical lab results, and the lab results were not documented in the resident's chart. Resident #44, admitted with chronic kidney disease, diabetes, and heart failure, had physician orders for several lab tests dated 11/8/24. However, the facility failed to obtain these labs, and there was no documentation of the lab results in the resident's medical record. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the labs were not drawn as ordered, and the physician was not notified to obtain new orders. The resident's medical condition required close monitoring, and the failure to conduct the ordered labs could have impacted their care. The deficiencies highlight a breakdown in communication and protocol adherence within the facility, particularly concerning the handling of critical lab results and the execution of physician orders. The lack of timely notification to the physician and the failure to obtain necessary lab tests for residents with serious medical conditions resulted in delayed treatment and potential harm to the residents involved.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for several residents, leading to deficiencies in addressing their specific medical and psychological needs. Resident #18, who was admitted with PTSD, anxiety, and depression, had a care plan that was not individualized to include specific triggers and interventions for managing PTSD. The Regional Nurse acknowledged that the care plan lacked direction for direct care staff on managing the resident's PTSD and associated behaviors. Resident #11, diagnosed with PTSD, anxiety, and borderline personality disorder, did not have a care plan addressing PTSD. The Regional Nurse confirmed the absence of a care plan for PTSD, which is necessary for residents with such a diagnosis. Similarly, Resident #12, with a history of suicidal ideation, did not have a care plan to monitor mental well-being and physical safety, despite the discharge paperwork indicating a history of suicidal ideation. The Social Worker was unaware of the absence of a care plan for suicidal ideation. Resident #44, who has a cardiac pacemaker, did not have a comprehensive care plan detailing the management and monitoring of the pacemaker. The care plan lacked information on how the pacemaker is monitored, and there was confusion among staff regarding the presence of the pacemaker. The Director of Nurses and Nurse Practitioner both indicated that the medical record should reflect the presence of a pacemaker to ensure staff awareness and proper care.
Invalid Execution of Advanced Directive
Penalty
Summary
The facility failed to accurately execute an Advanced Directive for a resident, specifically the Massachusetts Medical Order for Life Sustaining Treatment (MOLST). The MOLST form, which indicated Do Not Resuscitate and Do Not Intubate and Ventilate orders, was signed by a nurse practitioner and another individual who was not the resident. There was no evidence in the medical record of a physician's order or documentation indicating that the resident had an invoked health care proxy agent, which would authorize someone else to make health care decisions on their behalf. The resident, who was admitted to the facility with diagnoses including muscle wasting, sepsis, chronic obstructive pulmonary disease, atherosclerotic heart disease, and peripheral vascular disease, had a moderately intact cognition as per the Minimum Data Set assessment. During an interview, the Social Worker confirmed that the resident's health care proxy was not invoked, and the person who signed the MOLST did not have the authority to make health care decisions for the resident, rendering the MOLST invalid.
Failure to Notify Physician of Resident's Skin Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with a fungal infection in the groin area. The resident, who has a history of COPD, chronic respiratory failure, and schizophrenia, reported the issue to the nursing staff but did not receive the necessary antifungal treatment. The resident attempted to self-treat with over-the-counter powder, which was ineffective. Despite the resident's complaints, there was no physician's order for antifungal powder, and the progress notes did not indicate that the physician was informed of the condition. The facility's weekly skin reviews noted the condition of the resident's groin as pink and indicated that antifungal powder was applied, but there was no evidence of a physician's order for this treatment. The Regional Nurse confirmed that the physician should have been notified of the resident's condition. This oversight represents a failure to adhere to the facility's policy on promptly notifying the physician of changes in a resident's medical condition.
Deficiencies in Monitoring and Treatment for Residents on Anticoagulants and Skin Management
Penalty
Summary
The facility failed to ensure quality care for two residents, leading to deficiencies in monitoring and treatment. For one resident, who was on anticoagulant medication, the facility did not identify or document areas of discoloration consistent with bruising. Despite the resident's use of multiple blood thinners and the presence of red discolorations on their arms, the nursing staff did not report these changes to the physician or document them in the resident's medical records. The facility's policy required monitoring for complications related to anticoagulation therapy, but this was not adhered to, as evidenced by the lack of documentation and communication regarding the resident's condition. Another resident experienced a deficiency in care related to skin management. This resident reported a fungal infection in the groin area, but the facility failed to obtain a treatment for the condition. Although the resident had informed the nursing staff about the issue, there was no physician's order for antifungal powder, and the progress notes did not indicate that the physician was notified of the resident's request for treatment. The weekly skin reviews noted the application of antifungal powder, but there was no corresponding order or documentation to support this treatment. These deficiencies highlight a lack of adherence to the facility's protocols for monitoring and documenting changes in residents' conditions. The failure to communicate and document these issues resulted in inadequate care for the residents, as their medical needs were not properly addressed or managed according to the facility's policies.
Failure to Conduct Smoking Assessment and Develop Care Plan
Penalty
Summary
The facility failed to ensure that a smoking assessment was completed and a care plan was developed for a resident who smoked. The facility's policy requires that residents' smoking status be evaluated upon admission and re-evaluated quarterly or upon significant change. However, for the resident in question, there was no Safe Smoking Evaluation or person-centered care plan for smoking, despite the resident being listed as requiring supervised smoking. The resident was admitted with several medical conditions, including chronic obstructive pulmonary disease and atherosclerotic heart disease, and initially indicated no tobacco use on the Minimum Data Set assessment. Interviews revealed that the resident resumed smoking after feeling better post-admission, but this change was not documented in a care plan or evaluated for safety. The Social Worker acknowledged that a smoking agreement was signed upon admission, but no safe smoking evaluation was conducted. The Administrator added the resident to the supervised smoking list after observing the resident smoking outside, but confirmed that a care plan and evaluation should have been in place. This oversight indicates a lapse in following the facility's smoking policy and ensuring resident safety.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. For Resident #18, the facility did not adhere to the physician's order for oxygen therapy, as the oxygen concentrator was set to 4 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was observed by the surveyor and confirmed by Nurse #2, who acknowledged the error after reviewing the resident's physician orders. Resident #18, who has severe cognitive impairment and COPD, stated that only staff adjust the oxygen concentrator settings. Resident #6, diagnosed with COPD and chronic respiratory failure, was observed receiving 4.5 liters per minute of oxygen, exceeding the physician's order of 1 to 3 liters per minute. Additionally, the oxygen tubing was not changed as required, despite the medical record inaccurately indicating it had been replaced. Nurse #5 confirmed these issues during an interview. For Resident #12, who has dementia and COPD, the facility failed to obtain a physician's order for oxygen use, despite the resident using oxygen at night. Nurse #2 and the Assistant Director of Nursing confirmed the absence of a physician's order for Resident #12's oxygen therapy.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for one resident, leading to a deficiency. Specifically, the surveyor observed that medication was left unattended at the bedside of a resident who was cognitively intact and did not reject care. The facility's policy requires that all medications be stored in locked compartments and administered by authorized personnel, who must remain with the resident until the medication is consumed. However, this protocol was not followed, as evidenced by the presence of three medicine cups with 15 tablets, identified as calcium carbonate Tums, left on the resident's bedside table. The resident, admitted in April 2019, had a diagnosis of gastroesophageal reflux disease and was prescribed calcium carbonate tablets to be taken with meals. The medical record did not indicate that a self-medication administration assessment had been completed for the resident. Interviews with nursing staff, including a nurse and the Assistant Director of Nursing, confirmed that the facility's procedure is for nurses to stay with residents during medication administration to ensure all medications are taken, and that medications should not be left at the bedside. This lapse in protocol led to the observed deficiency.
Delayed Occupational Therapy Evaluation for Resident
Penalty
Summary
The facility failed to provide specialized rehabilitative services in a timely manner for a resident who was admitted with hemiplegia and hemiparesis following a stroke. The resident, who had moderate impaired cognition, complained of pain and stiffness in the left-hand joints, prompting a doctor's order for Biofreeze gel and a referral to occupational therapy (OT). However, the OT evaluation was delayed, as the facility did not have an OT on staff and relied on per diem OT staff who were only available once a month. The Assistant Director of Nursing acknowledged that the OT evaluation was conducted nearly a month after the initial complaint, which exceeded the facility's expectation of completing therapy screens within two weeks. The Rehab Director confirmed the lack of an on-staff occupational therapist and stated that residents should be evaluated as soon as possible after a therapy screen request.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of medical records for three residents, leading to discrepancies in documentation and care. For one resident with COPD, the oxygen delivery rate was inaccurately documented. The resident was observed receiving oxygen at 4.5 liters per minute, contrary to the physician's order of 2 liters per minute. The Medication Administration Record (MAR) inaccurately reflected the ordered rate, and nursing notes did not document the actual rate being administered. Interviews with nursing staff confirmed the discrepancy, and the resident stated that only staff adjusted the oxygen concentrator. Another resident, also with COPD and other conditions, experienced inaccuracies in documentation related to oxygen therapy and skin treatment. The resident was observed receiving oxygen at a rate higher than ordered, and the oxygen tubing was not changed as documented. Additionally, the resident reported a fungal infection for which no physician's order for antifungal powder was obtained, despite documentation indicating otherwise. Interviews with nursing staff confirmed the inaccuracies in the medical record and the lack of a physician's order for the antifungal treatment. A third resident with peripheral vascular disease and lymphedema had discrepancies in wound dressing documentation. The resident's medical record indicated that wound dressings were changed daily, but observations and interviews revealed that the dressing had not been changed as documented. The Assistant Director of Nursing confirmed that floor nurses were responsible for ensuring wound treatments were completed and documented accurately, highlighting a failure in maintaining accurate medical records and following physician orders.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the condition of several resident rooms and shower areas. Observations revealed that five out of thirteen resident rooms on Unit A had baseboard heaters in disrepair, with missing or damaged covers, exposing sharp edges and heating elements. Additionally, three out of three resident shower rooms were found to be dirty, with black mildew-like substances on the ceilings and grout between tiles, and one shower room had a non-functional exhaust fan, contributing to a musty and humid environment. Interviews with residents and staff corroborated these findings. A resident reported that the shower on Unit C was not kept clean, and the Director of Environmental Services acknowledged that the shower rooms were expected to be cleaned daily, but the exhaust fan in one shower room was not operating consistently. The facility's policies did not address the general maintenance of resident care areas or the upkeep of baseboard heaters, and the Administrator admitted that the facility had identified the issue with baseboard heater covers a year ago but had not completed the necessary replacements.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food provided to residents on Unit A was served at safe and appetizing temperatures. The facility's policy indicated that food should be maintained at proper temperatures, with hot foods served between 120 to 140 degrees Fahrenheit based on resident preference. However, during a test tray observation, it was found that the temperatures of several food items were below the required range, with puree beef at 109.9 degrees, mashed potatoes at 104.4 degrees, puree carrots at 103.6 degrees, and a hot dog at 97.3 degrees. These temperatures were significantly lower than the facility's policy and the Food Service Director's stated expectation of 135 degrees at the time of service. Additionally, the food was described as tepid, bland, and not palatable by the surveyor and residents. Interviews with residents revealed dissatisfaction with the food quality, with complaints about meals being cold and lacking variety. The Food Service Director acknowledged the issue, attributing it to a malfunctioning steam table well and the absence of a pellet system to keep plates warm. The Administrator also noted the need for a pellet system to maintain food temperatures. The deficiency was further supported by a Department of Public Health Consumer Complaint Form and Dining Committee Minutes, which documented resident complaints about food temperatures and quality.
Sanitation and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, where all food items are prepared and plated before being served to residents. Observations revealed that the reach-in freezers and refrigerators had large areas of fingerprints and smears, and the freezer doors lacked plastic protective pieces, leaving exposed metal edges that could collect debris. The facility's policy on sanitation and infection control, which requires the Dietary Manager to supervise all sanitation procedures and develop a cleaning schedule, was not adequately followed. The Food Service Director acknowledged the need for a better cleaning schedule and confirmed that the freezer and refrigerator doors should be cleaned every shift. Additionally, the facility did not ensure that kitchen staff adhered to sanitary standards during food handling. Two cooks were observed handling food without wearing appropriate hair restraints, such as hair nets or beard nets, as required by the facility's personal hygiene policy. Cook #1 plated food items without a beard net, and Cook #2 prepared sandwiches without a cap or hair net. The Food Service Director and the Administrator both stated that all dietary staff were expected to wear hair coverings in the kitchen, indicating a lapse in adherence to the facility's hygiene policies.
Failure to Update and Implement Elopement Care Plans
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was at high risk for elopement after an incident where the resident attempted to leave the facility. The resident, diagnosed with hereditary ataxia, mild cognitive impairment, and repeated falls, was found outside in the parking lot after an argument with a roommate. Despite being redirected back into the facility, no new interventions were added to the resident's care plan to address the elopement risk. A subsequent incident occurred where the resident left the facility unattended and returned with bruises and abrasions, yet the care plan remained unchanged. Another resident, diagnosed with Alzheimer's Disease and assessed to be at high risk for elopement, did not have an individualized comprehensive care plan addressing the risk of elopement. The facility's policy required that care plans include strategies and interventions for residents identified at risk for wandering or elopement, but this was not implemented for the second resident. The Director of Nurses acknowledged that a care plan should have been developed once the risk was identified.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent two incidents of elopement involving a resident who was assessed as being at high risk for elopement and was moderately cognitively impaired. On two separate occasions, the resident was able to leave the facility without staff knowledge. The first incident occurred when the resident was found in the parking lot adjacent to the facility, unescorted by staff. The second incident involved the resident being found a couple of blocks away from the facility with bruises and abrasions. The resident, admitted in July 2023, had diagnoses including hereditary ataxia, mild cognitive impairment, difficulty in walking, and repeated falls. The resident's care plan, reviewed in April 2024, identified the risk of elopement and included an intervention to make staff aware of this risk. However, after the first elopement incident, no new interventions were added to the care plan to prevent future occurrences. Interviews with staff revealed that the resident was able to exit through a back door that was not alarmed until later in the evening. Staff were unaware of the resident's absence until it was reported by a roommate. The Director of Nurses acknowledged that had she been aware of the resident's location during the first incident, additional interventions such as a wander guard bracelet and increased safety checks would have been implemented.
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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