Foremost At Sharon Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Sharon, Massachusetts.
- Location
- 259 Norwood Street, Sharon, Massachusetts 02067
- CMS Provider Number
- 225134
- Inspections on file
- 22
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Foremost At Sharon Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions developed MASD to the coccyx and was assessed by a Wound Nurse Practitioner, who made specific treatment recommendations. These recommendations were not communicated to the physician, no physician's order was obtained, and the treatments were not implemented. Nursing staff and the DON confirmed the expected process was not followed, and the lapse in communication and care was not explained.
A resident with dementia, diabetes, and other conditions developed a coccyx wound and sustained a fractured clavicle requiring a sling. Nursing staff did not create or update care plans to address the wound or fracture, including necessary interventions, treatment goals, or monitoring, despite facility policy and clear documentation of these needs. Interviews revealed confusion among staff about care plan responsibilities, resulting in the absence of comprehensive, person-centered care plans for the resident's changing conditions.
A resident with dementia and other chronic conditions developed a coccyx wound that was not assessed by the Wound Nurse Practitioner for three weeks after initial nursing documentation. The same resident sustained a clavicle fracture after a fall, and hospital discharge orders for a sling, non-weightbearing status, and arm monitoring were not implemented or documented by nursing staff. Interviews confirmed staff were unaware of the required care and the DON expected these interventions to be carried out and recorded.
A resident with dementia, diabetes, and a left clavicle fracture developed an open coccyx wound and required a sling with monitoring per hospital discharge instructions. Facility staff failed to document wound characteristics, progress, or the use and monitoring of the sling in the medical record, as required by facility policy. Interviews confirmed that expected assessments and documentation were not completed.
A resident with dementia and on anticoagulation experienced multiple falls over several months, yet staff failed to consistently update care plans or implement new fall prevention interventions after each incident, despite facility policy requiring individualized and ongoing reassessment. Staff interviews revealed inconsistent communication and follow-through regarding fall prevention strategies.
The facility did not complete required safety assessments of bed rails and mattresses after mattress changes for two residents with limited mobility using side rails, and failed to ensure a mattress extender was in place for another resident, resulting in unaddressed entrapment risks. Staff interviews revealed a lack of awareness about the need for these assessments, and documentation was incomplete.
A resident with anxiety and moderate cognitive impairment was prescribed multiple psychotropic medications, but the care plan failed to identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable treatment goals. Instead, the plan included generic interventions and listed behaviors not observed in the resident, as confirmed by staff and DON interviews.
A resident with dementia and atrial fibrillation experienced a broken partial upper denture, but the facility did not arrange timely dental services or document actions taken as required by policy. Despite requests from the resident and their representative, there was a prolonged delay before the resident was seen by a dentist, and the care plan and nutritional assessments did not address the missing denture or evaluate the resident's ability to eat and drink adequately.
A resident with diabetes and heart disease developed necrotic wounds and an infection on the right foot, but staff did not implement Enhanced Barrier Precautions (EBP) as required. For over a month, there was no EBP signage, PPE was not available, and a CNA provided high-contact care without gown or gloves. Nursing staff and the Infection Preventionist confirmed EBP should have been in place but could not explain the delay.
A resident with Alzheimer's and severe cognitive impairment developed a stage 2 pressure ulcer due to the facility's failure to implement timely treatment changes. Despite being at high risk and under the care of a Wound Care Consultant, the facility delayed notifying the physician and implementing new treatment recommendations, resulting in the deterioration of the resident's condition.
A resident with dementia and neurogenic bladder experienced severe complications due to improper Foley catheter management at an LTC facility. The catheter was not positioned correctly, leading to kidney swelling and a UTI. The facility failed to document catheter care, monitor intake and output, and notify the provider of abnormal radiology results, resulting in the resident's hospitalization.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in water management, PPE usage, and medication storage. The water management program did not accurately document temperatures, risking Legionella spread. Staff did not follow contact precautions for a resident with C-diff, and an oral syringe was improperly stored, risking contamination.
The facility's arbitration agreement did not initially provide for a neutral venue agreed upon by both parties. A review showed that 45 residents had signed the agreement without this provision. Interviews confirmed the agreement was recently updated to include a neutral venue, but only 11 residents had signed the revised version.
A resident with Alzheimer's and MASD developed a stage 2 pressure ulcer, but the facility failed to promptly notify the physician or implement the recommended treatment. The DON claimed to have informed the physician, but the physician and NP were unaware of the change. The delay in communication led to a three-day gap before the physician was notified and a four-day delay in starting the new treatment.
A facility failed to accurately complete an MDS assessment for a resident, incorrectly documenting their pressure ulcer risk. Despite a Norton Plus Pressure Ulcer Scale assessment indicating a very high risk, the MDS assessment recorded no risk. The MDS Coordinator admitted the mistake and noted the need for correction.
A facility failed to update a resident's care plan to reflect a newly developed Stage 2 pressure ulcer and a change in treatment. The resident, with Alzheimer's and MASD, was dependent on staff for repositioning. Despite a Wound Care consultant's recommendation for treatment changes, the care plan was not revised. Nurse #1 confirmed the oversight during an interview.
A resident with type two diabetes did not receive ordered blood glucose monitoring before meals due to a failure in implementing a physician's order. Despite the order being entered and confirmed in the EHR, there was no documentation of fingersticks or glucose values for several days, resulting in 35 missed monitoring opportunities. Interviews with staff and the DON highlighted the expectation for timely implementation and documentation of such orders.
The facility failed to secure hazardous items in the Borderland Unit, a secure Dementia Special Care Unit, where three residents were observed wandering. Unlocked storage areas contained oxygen tanks, razors, and other potentially dangerous items, posing a risk to residents. The Activity Director acknowledged the need for these areas to be secured to prevent resident access.
A resident receiving anticoagulation therapy with Lovenox, Clopidogrel, and Aspirin was not monitored for adverse consequences, despite being at high risk for bleeding complications. The facility's physician and DON confirmed the lack of a monitoring order, which is standard practice for such medications.
A facility failed to monitor a resident for potential adverse consequences and behaviors when administering antidepressant medication. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Mirtazapine and Trazodone without proper monitoring for 16 days. Interviews with staff revealed an expectation for monitoring, which was not documented, indicating a lapse in policy adherence.
The facility exceeded the acceptable medication error rate of 5%, reaching 7.14% due to errors by two nurses. One nurse administered the wrong formula of Senna to a resident, while another failed to administer Artificial Tears to another resident. Both errors were acknowledged by the nurses involved.
The facility failed to ensure proper storage and administration of medications, leading to deficiencies. A resident's Albuterol inhaler was left on the overbed table without an order for self-administration, and medication carts were observed unlocked and unattended. The DON confirmed that medications should be secured when not in use.
A facility failed to maintain a bladder scanner, as documented in their assessment, leading to a resident's hospitalization. The resident, with dementia and neurogenic bladder, experienced worsening symptoms due to a malpositioned Foley catheter. Despite concerns, the facility lacked a bladder scanner to assess urine retention, resulting in bilateral hydroureteronephrosis and impaired kidney function. Interviews confirmed the absence of the scanner, contradicting the facility's documented resources.
Failure to Notify Physician and Implement Wound Care Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician of new wound care recommendations made by the Wound Nurse Practitioner for Moisture-Associated Skin Damage (MASD) to the resident's coccyx. The resident, who had diagnoses including unspecified dementia, seizures, syncope, hypertension, muscle weakness, and type 2 diabetes mellitus, was assessed by the Wound Nurse Practitioner, who documented specific treatment recommendations. These recommendations included cleaning the wound with normal saline, patting dry, and applying zinc and collagen sprinkles daily. However, there was no documentation that the physician was notified of these recommendations, no physician's order was obtained, and the recommended treatments were not implemented as evidenced by the absence of documentation in the Treatment Administration Record and progress notes. Interviews with nursing staff and the DON confirmed that the expected process was for nurses to notify the physician of the Wound Nurse Practitioner's recommendations and obtain an order to implement the new treatments. The nurse assigned to the resident was unaware of the Wound Nurse Practitioner's involvement and recommendations, and could not explain why the physician was not notified. The physician also stated she was not aware of the recommendations and would have implemented them if notified. The DON reiterated the expectation for physician notification and order acquisition but could not explain the lapse in communication and implementation.
Failure to Develop and Implement Comprehensive Care Plans for Wound and Fracture
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan for a resident who developed a wound on the coccyx and sustained a fractured left clavicle. Despite facility policy requiring care plans to include objectives, timetables, and measurable outcomes, there was no documentation of a care plan addressing the resident's new open area and Moisture-Associated Skin Damage (MASD) to the coccyx. The wound was identified through skin assessments and nurse progress notes, and a wound nurse practitioner provided treatment recommendations. However, nursing did not document the wound location in the care plan or update it with interventions, treatment goals, and outcomes as required. Additionally, after the resident sustained a left clavicle fracture and was discharged from the hospital with instructions for sling use and monitoring, there was no care plan developed to address the fracture, use of the sling, non-weight bearing status, or monitoring for complications such as numbness. The medical record lacked documentation of interventions, treatment goals, or outcomes related to the fracture and associated care needs during the relevant period. Interviews with nursing staff and the DON revealed confusion regarding responsibility for care plan development and updates. The DON stated that both staff nurses and the MDS nurse were responsible for initial care plans, with the MDS nurse updating them as needed. However, the expected comprehensive care plans addressing the resident's wound and fracture were not developed or implemented, contrary to facility policy and expectations.
Delayed Wound Assessment and Failure to Implement Post-Fall Treatment Orders
Penalty
Summary
A resident with multiple diagnoses, including dementia, seizures, hypertension, muscle weakness, and diabetes, developed an open area on the coccyx that was first identified by nursing staff on 8/22/25. Despite documentation of the wound on several occasions, the resident was not evaluated or assessed by the facility's Wound Nurse Practitioner until 9/12/25, approximately three weeks after the initial identification. Both the assigned nurse and the Director of Nursing (DON) confirmed that the Wound Nurse Practitioner visits weekly and should have assessed the resident at the next scheduled visit, but this did not occur. Additionally, the same resident was assessed as high risk for falls and experienced a fall resulting in a left clavicle fracture. Following the fall, the resident was transferred to the hospital emergency department (ED), where discharge instructions included the use of a sling, maintaining non-weightbearing status on the left arm, and daily monitoring of the skin around the sling. Upon return to the facility, there was no documentation in the medical record, treatment administration record, or nursing progress notes to indicate that these orders were implemented or that the resident's left arm was monitored as directed. Interviews with nursing staff revealed a lack of awareness regarding the resident's fall, fracture, and the specific post-hospital care instructions. The DON stated that it was expected for staff to implement and document hospital discharge orders, including the use of a sling and monitoring of the affected arm, but this was not done for the resident in question.
Failure to Maintain Complete and Accurate Medical Records for Wound and Orthopedic Care
Penalty
Summary
A deficiency was identified when the facility failed to maintain a complete and accurate medical record for a resident who developed an open area on the coccyx and had a left clavicle fracture. The facility's policies required documentation of services provided, progress toward care plan goals, and any changes in the resident's condition, as well as detailed wound assessments and treatment documentation. However, for the resident in question, there was no nursing documentation regarding the characteristics or progress of the coccyx wound, nor was there evidence that a pressure form was implemented as required by facility policy. Additionally, the resident returned from the hospital with a discharge summary recommending the use of a sling for the left arm, daily monitoring of the skin around the sling, and maintaining non-weight bearing status until further orthopedic evaluation. Despite these recommendations, there was no documentation in the medical record, physician orders, Treatment Administration Record, or Nurse Progress Notes to support that the resident's left arm was placed in a sling, monitored by nursing staff, or that non-weight bearing status was maintained. Interviews with nursing staff and the DON confirmed that these actions were expected but not documented or, in some cases, not performed. The lack of documentation and follow-through on both wound care and orthopedic management represented a failure to adhere to the facility's own policies and accepted professional standards for medical recordkeeping. This deficiency was substantiated through record review and staff interviews, which revealed gaps in both assessment and documentation for the resident's identified medical needs.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent avoidable accidents, specifically repeated falls, for a resident with dementia and atrial fibrillation on anticoagulation. Despite the resident being identified as high risk for falls through multiple Morse Fall Scale evaluations and having a documented history of nine falls over several months, the facility did not consistently develop or update individualized fall prevention interventions after each incident. The care plans reviewed did not reflect new or revised interventions following several of the resident's falls, and only one new intervention was implemented after two falls on the same day. The facility's own policies require that staff identify and implement resident-specific interventions based on ongoing assessments and that care plans be updated when outcomes are not met or when a resident experiences significant changes, such as repeated falls. However, documentation and interviews revealed that the process for updating care plans and implementing new interventions was not consistently followed. Nurses did not routinely update care plans immediately after a fall, and the Director of Nursing confirmed that a new intervention should have been implemented after every fall, which did not occur in this case. Interviews with staff indicated a lack of clarity and consistency in communication and implementation of fall prevention strategies. Certified Nursing Assistants relied on nurses to inform them of new interventions, but nurses did not always update care plans or communicate changes promptly. The resident continued to experience falls, some resulting in injury and hospital transfers, without evidence of a systematic approach to reassessing and modifying interventions as required by facility policy.
Failure to Assess Bed Rail and Mattress Safety After Changes
Penalty
Summary
The facility failed to conduct required safety inspections and assessments of bed rails and mattresses for three residents, resulting in unaddressed risks of entrapment. Specifically, two residents with limited mobility who utilized bilateral side rails received new air mattresses, but the facility did not complete new assessments of the bed, side rails, and mattresses for potential entrapment after the mattress changes. Documentation did not show that these beds had ever been measured for entrapment risk following the changes, despite the residents' ongoing use of side rails and pressure-reducing devices. For another resident, the facility did not ensure that a mattress bolster or extender was in place to fill a significant gap between the mattress and the footboard, leaving the metal bed frame exposed. Multiple observations confirmed a gap of approximately six inches at the foot of the bed, with no filler piece installed, despite the resident's continued use of the bed. The last documented assessment for this resident was outdated and did not reflect the current mattress in use. Interviews with facility staff revealed a lack of awareness regarding the requirement for regular side rail safety assessments, particularly when mattresses are changed. The maintenance director was unaware of the need for these assessments, and the regional maintenance director acknowledged that inspections should have been conducted after mattress changes. The documentation provided by the facility was incomplete and did not include the necessary assessments for the affected residents.
Failure to Individualize Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with generalized anxiety disorder who was prescribed Buspirone, Trazodone, and Sertraline for anxiety. The care plan did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment, as required by the facility's own policy. Instead, the care plan included generic interventions and listed behaviors that were not observed in the resident, such as disrobing, inappropriate responses to verbal communication, and aggression toward staff or others. Record reviews showed that the resident had moderate cognitive impairment, required assistance with activities of daily living, and received daily antianxiety and antidepressant medications. The social service and nursing assessments described the resident as pleasant, social, and occasionally perseverative, with no history of the specific behaviors listed in the care plan. The care plan interventions were pre-populated and not tailored to the resident's actual symptoms or needs. Interviews with nursing staff and the DON confirmed that the behaviors listed in the care plan were not exhibited by the resident and that the care plan should have included only resident-specific signs, symptoms, and behaviors. The DON acknowledged that the care plan was missing non-pharmacological interventions and measurable goals of treatment, and that the use of batch orders in the electronic medical record may have contributed to the lack of individualization.
Failure to Provide Timely Dental Services for Damaged Denture
Penalty
Summary
The facility failed to provide timely dental services for a resident who was admitted with dementia and atrial fibrillation. The resident's partial upper denture broke, and although the issue was identified and a dental referral was requested, there was a significant delay in arranging for dental evaluation and replacement. Documentation shows that the resident's denture broke in October, and while the family and staff attempted to coordinate dental care, the resident was not seen by a dentist until May of the following year. The facility's policy required referral for dental services within three days of denture damage or loss, with documentation of actions taken and reasons for any delay, but this was not followed. Additionally, the resident's care plan and nutritional evaluations did not reflect the broken or missing denture, nor was there evidence that the resident was assessed to ensure adequate eating and drinking while awaiting dental services. Interviews with staff and the resident's representative confirmed the delay and lack of timely intervention. As of the survey exit, there was no documentation that a new partial upper denture had been ordered for the resident.
Failure to Implement Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with wounds on the right foot, as required by the facility's infection control policy. The resident, who had diagnoses including diabetes mellitus and atherosclerotic heart disease, was identified as having necrotic areas and an infection on the right foot. Despite the presence of wounds and a superimposed infection, EBP was not initiated until 31 days after the wounds were first identified. During this period, there was no EBP signage posted outside the resident's room, and personal protective equipment (PPE) such as gowns and gloves was not readily available for staff use. Observations by the surveyor revealed that a CNA provided high-contact care to the resident without wearing the required PPE. Interviews with nursing staff, the Infection Preventionist, and the Director of Nursing confirmed that EBP should have been implemented when the wounds were first identified, but none could explain the delay. The medical record review also failed to show any documentation of EBP being put into place at the appropriate time, indicating a lapse in adherence to infection control standards.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent and promote healing of a pressure injury for a resident, leading to the development of a stage 2 pressure ulcer. The resident, who had Alzheimer's disease and was non-ambulatory, was at very high risk for developing pressure ulcers due to severe cognitive impairment, dependency on staff for repositioning, and incontinence. Despite being seen weekly by a Wound Care Consultant, the facility did not implement timely treatment changes as recommended by the consultant. The Wound Care Consultant initially recommended a treatment plan for the resident's Moisture-Associated Skin Damage (MASD), which included incontinence care and the application of collagen powder with barrier cream. However, the facility delayed implementing a new treatment plan when the MASD worsened, and the wound increased in size. The consultant's recommendations for a change in treatment were not communicated promptly to the attending physician or implemented in a timely manner, resulting in a delay of several days. The deficiency was further compounded by a lack of communication and coordination among the facility's staff. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) failed to ensure that the physician was notified of the changes in the resident's condition and the new treatment recommendations. The physician and Nurse Practitioner (NP) were not informed of the development of the stage 2 pressure ulcer or the consultant's recommendations, leading to a significant delay in the implementation of appropriate care.
Failure in Foley Catheter Management Leads to Hospitalization
Penalty
Summary
The facility failed to provide proper Foley catheter care and management for a resident, leading to significant health complications. The resident, who was admitted with dementia and neurogenic bladder, had a Foley catheter that was not properly positioned, resulting in inadequate drainage from the bladder. This mismanagement led to bilateral hydroureteronephrosis, impaired kidney function, and a urinary tract infection, ultimately requiring hospitalization. The facility's policies on catheter care, intake and output monitoring, and documentation were not followed. There was no documented evidence of the care and maintenance of the Foley catheter, nor was there evidence of intake and output monitoring as ordered by the nurse practitioner. Additionally, the facility failed to notify the resident's provider of an abnormal radiology report, which indicated a distended urinary bladder and suggested further evaluation was necessary. Interviews with facility staff revealed a lack of adherence to established procedures and communication failures. The nursing staff did not document the necessary care or follow up on the abnormal findings, leading to the resident's hospitalization. The Director of Nurses and Director of Clinical Services confirmed the absence of documentation and orders related to the resident's care, highlighting a significant deficiency in the facility's management of the resident's condition.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Firstly, the facility did not implement a comprehensive water management program to minimize the risk of Legionella and other pathogens in the building's water systems. The facility's policy required accurate measurement and documentation of water temperatures, but the Maintenance Director and Regional Maintenance Director failed to record the temperatures of the hot water tanks on multiple occasions. Additionally, the water temperatures recorded were consistently below the acceptable range, indicating a failure to control the introduction and spread of Legionella. Secondly, the facility did not adhere to proper infection control precautions for Resident #211, who was diagnosed with enterocolitis due to Clostridium difficile (C-diff) and sepsis. Staff members, including a social worker and a certified nursing assistant, were observed entering the resident's room without wearing the required personal protective equipment (PPE) and failing to perform hand hygiene upon exiting. This non-compliance with contact precautions increased the risk of infection transmission within the facility. Lastly, the facility did not properly store an oral syringe for Resident #35, as observed on the medication cart. The syringe was secured to a bottle of liquid medication with an elastic band, leaving the tip uncapped and exposed. This improper storage practice posed a risk of contamination, as confirmed by the nurse and the Director of Nurses during interviews.
Arbitration Agreement Lacked Neutral Venue Provision
Penalty
Summary
The facility failed to ensure their arbitration agreement provided for the selection of a neutral venue that is convenient to both parties. A review of the facility's arbitration agreements, which were in use until June 5, 2024, revealed that they did not indicate that residents or their representatives had the right to a neutral venue agreed upon by both parties. This deficiency was identified through a document review and interviews conducted on June 13, 2024. At that time, it was noted that 45 residents or their representatives had signed the facility's binding arbitration agreement, which lacked the provision for a neutral venue. Interviews with corporate staff and the Director of Admissions confirmed that the arbitration agreement was only recently updated to include this provision, and efforts were underway to have residents or their representatives sign the updated version. However, only 11 out of the 45 residents had signed the revised agreement by the time of the survey.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's physician or physician extender about a significant change in condition for a resident, leading to a delay in treatment. The resident, who had been diagnosed with Alzheimer's disease and moisture-associated skin damage (MASD) on the left buttock, developed a stage 2 pressure ulcer. The Wound Care Consultant identified the deterioration and recommended a new treatment plan, but the facility did not promptly inform the physician or implement the new treatment. The Director of Nursing (DON) claimed to have notified the physician of the new stage 2 pressure ulcer and the treatment recommendations, but the physician stated she was not informed. The Assistant Director of Nursing (ADON) admitted to being too busy to attend the wound care rounds and did not notify the physician after seeing the consultant's report. The Nurse Practitioner (NP) also confirmed not being informed about the change in the resident's condition or the new treatment recommendations. The delay in communication resulted in the physician being notified three days after the Wound Care Consultant's recommendations, and the new treatment order was not initiated until four days later. This lack of timely notification and implementation of the treatment plan violated the facility's policy on change of condition and documentation, which requires immediate notification of significant changes in a resident's condition.
Inaccurate MDS Assessment for Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the resident's risk for pressure ulcers. The resident, who was admitted in July 2017, had diagnoses including chronic kidney disease and adult failure to thrive. A Norton Plus Pressure Ulcer Scale assessment conducted on April 23, 2024, indicated that the resident had a score of 6.0, categorizing them as at very high risk for developing pressure ulcers. However, the most recent MDS assessment dated April 25, 2024, inaccurately documented that the resident was not at risk for developing pressure ulcers. During an interview, the MDS Coordinator acknowledged the error, stating that the incorrect entry was made by mistake and required modification to accurately reflect the resident's risk.
Failure to Update Care Plan for Stage 2 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and updated by the interdisciplinary team (IDT) as required. Specifically, the care plan was not revised to reflect a newly developed Stage 2 pressure ulcer and a change in treatment. The facility's policy mandates that care plans be revised when there is a significant change in a resident's condition, but this was not adhered to in the case of the resident who developed a Stage 2 pressure ulcer. The resident, who was admitted to the facility in July 2017, had diagnoses including Alzheimer's disease and Moisture Associated Skin Damage (MASD) on the left buttock. The resident was dependent on staff for turning and repositioning and was non-ambulatory. Despite the Wound Care consultant's note indicating the deterioration of MASD to a Stage 2 pressure ulcer and recommending a change in treatment, the comprehensive care plan was not updated to reflect these changes. Nurse #1 confirmed during an interview that the care plan was not updated to reflect the change in the resident's skin condition.
Failure to Implement Physician's Order for Blood Glucose Monitoring
Penalty
Summary
The facility failed to implement a physician's order to monitor blood glucose levels three times per day before meals for a resident with type two diabetes mellitus, among other diagnoses. The resident was admitted with severe cognitive impairment and had orders for insulin and Metformin, along with fingerstick blood glucose monitoring before meals. Despite the physician entering the order into the Electronic Health Record (EHR) and a nurse confirming it, there was no documentation of the fingersticks or blood glucose values from the specified start date until several days later. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the order was confirmed but not implemented, and the expected documentation was missing. The physician and DON both expressed expectations that the order should have been carried out and documented promptly. The oversight resulted in 35 missed opportunities for blood glucose monitoring, which was crucial for managing the resident's diabetes and preventing complications.
Unsecured Hazardous Items in Dementia Unit
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards on the Borderland Unit, a secure Dementia Special Care Unit. During an observation, the surveyor noted that a storage closet and a storage area in the shower room were not securely locked, making hazardous items easily accessible to wandering residents. Specifically, the surveyor found two oxygen concentrators, two filled portable oxygen tanks, and a three-tiered cart with shampoo and body wash in an unlocked storage room. Additionally, a storage closet with a numerical combination lock was not properly secured, allowing access to items such as disposable razors, body lotion, A & D ointment, mouthwash, and shaving cream. The surveyor observed three residents wandering the hallways of the Borderland Unit, indicating the potential risk of these unsecured hazardous items being accessed by residents. The Activity Director confirmed that the doors to the storage closet and storage room should be closed to prevent resident access to potentially hazardous items. The failure to secure these areas represents a deficiency in providing a safe environment for residents, particularly those with dementia who may wander and inadvertently access dangerous items.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to monitor adverse consequences of anticoagulation medication for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including cerebral infarction, hypertension, and severe cognitive impairment, was prescribed Lovenox, Clopidogrel, and Aspirin. Despite the high risk of bleeding complications due to the combination of these medications, there was no physician's order to monitor for potential side effects or adverse complications related to the anticoagulant therapy. Interviews with the physician and the Director of Nursing confirmed that it was standard practice to monitor for bleeding and bruising in residents receiving anticoagulant medication. However, a review of the resident's past and current physician's orders revealed the absence of such an order. The Director of Nursing acknowledged that the resident should have been monitored for adverse consequences of the anticoagulation medications, but this was not done.
Failure to Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor the resident for potential adverse consequences and behaviors when administering antidepressant medication. The resident, who was admitted with diagnoses including depression, anxiety disorder, cerebral infarction, and dysarthria/anarthria, had a severe cognitive impairment as indicated by a BIMS score of 6 out of 15. The resident was prescribed Mirtazapine and Trazodone, but there was no physician's order for monitoring potential side effects or behaviors related to these medications for a period of 16 days. Interviews with facility staff, including a nurse and the physician, revealed that there was an expectation for residents on antidepressants to be monitored for side effects such as drowsiness. However, the resident's medical record lacked documentation of such monitoring during the specified period. The Director of Nursing confirmed that the resident should have been monitored for side effects and behaviors throughout the course of the antidepressant treatment, indicating a lapse in adherence to the facility's policy and state/federal regulations.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.14% during the survey. This was due to two errors made by two out of three nurses observed. Nurse #2 administered the incorrect formula of Senna to Resident #29. Instead of giving Senna as per the physician's orders, Nurse #2 administered Senna-S, which is a combination drug containing both Senna and Colace, a stool softener. This error was acknowledged by Nurse #2 during an interview, where she confirmed the mistake in medication administration. Additionally, Nurse #3 failed to administer Artificial Tears to Resident #1, despite preparing the medication. The surveyor observed that Nurse #3 did not bring the Artificial Tears into the resident's room during the medication administration process. Nurse #3 admitted in an interview that she should have administered the Artificial Tears while in the room but did not. The Director of Nursing confirmed that the expectation was for medications to be administered according to the physician's orders.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications and biologicals, leading to several deficiencies. For one resident, an Albuterol inhaler was observed on the overbed table on multiple occasions, despite the resident not having an order to self-administer medications or a care plan indicating the ability to do so. Interviews with the resident and nursing staff revealed that the resident was not informed about the need to lock the inhaler away when not in use, and the facility had not provided a means for safe storage. The Director of Nurses confirmed that medications should not be at the bedside if the resident has not been assessed for self-administration. Additionally, the facility failed to ensure that medication and treatment carts were locked when not under direct supervision. Observations showed that treatment carts were left unlocked and unattended in hallways, with residents roaming nearby. In one instance, a nurse left artificial tears on top of a medication cart while attending to a resident, leaving the cart unattended and out of eyesight. The Director of Nurses acknowledged that all medications should be locked in the cart when unattended.
Failure to Maintain Bladder Scanner Leads to Resident Hospitalization
Penalty
Summary
The facility failed to implement their facility assessment by not maintaining a bladder scanner, which was documented as available in their resources. This deficiency led to a significant medical incident involving a resident who was admitted with dementia and neurogenic bladder. The resident was severely cognitively impaired and had an indwelling catheter. Despite concerns about urine retention, the facility was unable to use a bladder scanner to assess the resident's condition due to its unavailability. The resident's condition worsened, leading to hospitalization after being transferred due to a distended abdomen. Hospital records indicated that the resident had bilateral hydroureteronephrosis, impaired kidney function, and a urinary tract infection. The Foley catheter was found to be malpositioned, and after replacement, a significant amount of urine was drained, leading to improvement in the resident's condition. Interviews with facility staff, including the Director of Nurses and the Regional Director of Operations, confirmed the absence of a bladder scanner, contradicting the facility assessment document. The Regional Director of Operations acknowledged the discrepancy and indicated that the bladder scanner might have been broken, highlighting a failure in resource management and assessment implementation.
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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