Garden Place Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Attleboro, Massachusetts.
- Location
- 193-195 Pleasant Street, Attleboro, Massachusetts 02703
- CMS Provider Number
- 225267
- Inspections on file
- 20
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Garden Place Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain a safe environment by leaving hazardous items accessible to cognitively impaired residents, not providing a wander guard for a high-risk resident, and leaving alcohol unsecured in a resident's room. Hazardous items like bleach wipes, razors, and medications were not properly secured, and a resident at high risk for elopement was not given a wander guard. Additionally, alcohol brought in by family was left unsecured in a resident's room, despite the presence of a roommate with a history of substance use disorder.
The facility failed to follow food safety and sanitation standards, leading to potential foodborne illness risks. Observations revealed improperly dated and stored food items, unclean ice machines with growths, and unsanitary conditions in a kitchenette. Staff interviews confirmed the lack of adherence to policies for dating and discarding food, and the absence of a cleaning schedule for ice machines.
A facility failed to maintain an active court-approved treatment plan for a resident receiving antipsychotic medication. The resident, diagnosed with psychosis and other mental health conditions, was administered Zyprexa without a current treatment plan due to delays in renewing the plan. Facility staff, including a social worker and administrator, acknowledged issues with documentation and communication with the facility lawyer, resulting in the absence of a scheduled court hearing for the renewal.
A facility failed to develop a comprehensive care plan for a resident undergoing chemotherapy for lung and rectal cancer. Despite being cognitively intact, the resident's care plan lacked details on cancer treatment. Interviews with staff, including nurses and the DON, confirmed the care plan was not updated to reflect the resident's current treatment, contrary to facility policy.
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. A resident with cancer did not receive Dexamethasone as prescribed, with missed doses and incomplete documentation. Another resident with heart conditions received Propranolol despite blood pressure readings below the prescribed threshold. These issues highlight a lack of adherence to medication administration and documentation protocols.
A resident with a toothache and aphthous ulcer did not receive prescribed pain relief medications consistently, despite frequent complaints of pain. The MAR showed that Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous were not administered over several days. Nursing staff failed to document or locate these medications, resulting in inadequate pain management.
A facility failed to provide appropriate dialysis care for a resident with an AV fistula in the left arm, crucial for long-term dialysis. The resident's care plan lacked specific instructions for the fistula's location and care, and there were no physician's orders for its monitoring. The facility's staff did not check the AV fistula site or dressing, and blood pressure was incorrectly taken from the arm with the fistula. Interviews confirmed the absence of necessary orders for monitoring and care, indicating a lapse in following professional standards.
A facility failed to assess a resident's trauma history and identify triggers, despite the resident's PTSD diagnosis. The resident, admitted with dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history, and a trauma care plan was not initiated. Social workers did not review hospital discharge paperwork or inquire about trauma history from the family, leading to a deficiency in trauma-informed care.
A facility failed to act on a Consultant Pharmacist's recommendation to conduct lab monitoring for a resident on Levothyroxine. The recommendation was not documented in the resident's medical record, and the prescriber did not review or act upon it. Interviews revealed that the DON was responsible for distributing recommendations, but there was no evidence of review, and the prescriber response section was blank.
A resident with dementia and a known toothache was admitted to the facility, but timely dental services were not provided. Despite frequent complaints of tooth pain and a care plan indicating a need for a dental referral, the facility failed to arrange a timely appointment. The resident was given pain management medications, but the dental referral remained pending. The DON acknowledged the lack of a scheduled visit from the in-house consultant dentist and did not refer the resident to a community dentist until prompted by a surveyor.
A resident developed redness and irritation on their facial area after being shaved by a staff member. The facility failed to document the nurse's assessment, physician notification, and treatment order for the razor burn. Despite administering bacitracin as ordered, the nurse did not complete an incident report or document the progress toward healing, violating the facility's policies on charting and incident reporting.
Failure to Maintain a Safe Environment and Secure Hazardous Items
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents on the secure unit, particularly for two residents. Hazardous items such as bleach wipes, razors, and medications were accessible to cognitively impaired residents. The surveyor observed an unsecured cabinet with bleach wipes and an unlocked medication cart. Additionally, the soiled utility room was accessible without a code, and razors were protruding from a full sharps container. Staff interviews revealed a lack of awareness and adherence to safety protocols regarding the secure storage of hazardous items. Resident #105, who was assessed at high risk for elopement due to severe cognitive impairment, was not provided with the necessary intervention of a wander guard. Despite being identified as at risk for elopement in the care plan and nursing admission assessment, the resident was not included in the Wander guard book, and no wander guard was initiated. The resident exhibited wandering behavior and expressed a desire to leave the facility, yet the interdisciplinary team was not notified, and the required safety measures were not implemented. Resident #79, who was cognitively intact, had alcohol brought in by family members that was not securely stored. The alcohol was left in the resident's room, despite the presence of a roommate with a history of substance use disorder. Staff interviews indicated that alcohol should be treated like medication, requiring a physician's order and secure storage. However, the process was not followed, and the alcohol remained unsecured, posing a potential risk to the resident and others.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and professional standards for food safety and sanitation, which could potentially lead to the spread of foodborne illnesses among residents. The surveyor observed multiple instances where food items were not properly dated and stored in the main kitchen and kitchenettes. Specifically, opened containers of thickened apple juice, dairy drinks, and other beverages were found without proper date markings, despite manufacturer instructions indicating they should be discarded after seven days of opening. Interviews with staff, including a nurse and the Food Service Director (FSD), confirmed that the expectation was for all thickened liquids to be dated when opened and discarded after seven days. The facility also failed to maintain four ice machines in a clean and sanitary condition. Observations revealed orange-brown and black growths inside the ice machines, with condensation and water dripping from these growths onto the ice. The ice machines were reportedly cleaned by a vendor every three months, but there was no schedule for the facility to clean them between vendor visits. The FSD and the Director of Maintenance acknowledged the presence of growths and the lack of a cleaning schedule, which was confirmed during interviews with the Administrator. Additionally, one of the unit kitchenettes was not maintained in a clean and sanitary condition. The surveyor noted an open floor drain with black and brown growth, a greenish-white slimy substance, and dead drain flies on the floor. The area was described as having an extremely warm air temperature and a damp smell. The Administrator and the Director of Maintenance recognized the need for cleaning and replacing the tile and area surrounding the drain to remove the growth, acknowledging that the floor should be clean and free of any growth.
Expired Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medications was active and current for a resident with a guardian. The resident, who was diagnosed with psychosis, major depressive disorder, and anxiety, was receiving Zyprexa, an antipsychotic medication, on a routine basis. The treatment plan, which authorized the administration of this medication, had expired, and there was no evidence of a renewed plan being in place. Interviews with facility staff, including a nurse, unit manager, and social worker, revealed that the renewal process was delayed due to issues with documentation and communication with the facility lawyer. The social worker indicated that the required paperwork for the renewal of the treatment plan had been sent to the facility lawyer multiple times, but it was deemed invalid and needed to be resubmitted. Despite efforts to restart and resubmit the necessary documentation, a court hearing had not been scheduled by the end of the survey. The facility administrator acknowledged the issues with the renewal process and confirmed that the treatment plans should be renewed annually for residents with guardians receiving antipsychotic medications. However, as of the survey's conclusion, there was no additional evidence that the required paperwork had been completed and submitted to the courts.
Failure to Implement Comprehensive Care Plan for Cancer Treatment
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with lung and rectal cancer, who was undergoing chemotherapy. Despite the resident being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the care plan did not address the resident's cancer treatment. This oversight was identified during a review of the resident's medical records, which showed no comprehensive care plan for the cancer and chemotherapy treatment. Interviews with facility staff, including nurses and the Director of Nurses, revealed a lack of adherence to the facility's policy on comprehensive person-centered care plans. Staff acknowledged that care plans should be updated to reflect significant changes in treatment plans or medication orders. However, it was confirmed that the resident's care plan did not include the necessary details for managing cancer treatment, despite the potential side effects and the importance of reflecting the resident's current treatment status.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. For Resident #33, who was admitted with lung and rectal cancer, the facility did not accurately transcribe, administer, and document the administration of Dexamethasone, a corticosteroid prescribed to manage inflammation related to chemotherapy. Despite clear orders to administer the medication twice daily on specific days surrounding chemotherapy sessions, the medication was not given as prescribed, and documentation was incomplete. Interviews with nursing staff revealed that doses were missed, and the medication was not properly recorded in the Medication Administration Record (MAR). For Resident #18, who had a history of transient ischemic attack, cerebral infarction, and chronic atrial fibrillation, the facility failed to adhere to physician orders regarding the administration of Propranolol, a medication used to manage heart conditions. The orders specified that the medication should not be given if the resident's systolic blood pressure was below 100. However, the MAR indicated that Propranolol was administered on multiple occasions when the resident's blood pressure was below the specified threshold. Interviews with nursing staff confirmed that the medication was given contrary to the physician's orders, and there was no documentation of any alternative instructions from the physician. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding medication administration and documentation. The facility's failure to ensure accurate transcription and administration of medication orders, as well as proper documentation in the MAR, resulted in missed doses and inappropriate administration of medications, potentially compromising resident care.
Inadequate Pain Management for Resident with Tooth Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with tooth pain, as observed by surveyors. Resident #105, who was admitted with a diagnosis of toothache and aphthous ulcer, frequently complained of tooth pain. Despite having orders for pain relief medications such as Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous, these were not consistently administered. The Medication Administration Record (MAR) showed that these medications were not given from October 31 to November 4, 2024, even though the resident continued to report pain. On November 3, 2024, the resident complained of tooth pain to a nurse, who acknowledged the complaint but failed to document the administration of Tylenol, which she claimed to have given. The nurse also admitted to not administering other prescribed medications like Lidocaine Viscous and Orajel, citing an inability to locate them. This lack of documentation and administration of prescribed pain relief measures contributed to the resident's ongoing discomfort. Interviews with nursing staff revealed a lack of awareness and availability of the prescribed medications. Nurse #4, who worked once a week, was aware of the Orajel order but could not find it, and was unaware of the Lidocaine Viscous. The Unit Manager confirmed that the Lidocaine was available but not administered, and the Orajel was missing from the medication cart. This indicates a breakdown in communication and medication management within the facility, leading to inadequate pain management for the resident.
Failure to Monitor and Care for Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with an arteriovenous (AV) fistula, which is crucial for long-term dialysis. The resident, who was admitted with end-stage renal disease and required dialysis three times a week, had an AV fistula in the left arm. The facility's policy required regular monitoring of the AV fistula site to prevent infection and ensure patency, including palpating for a thrill and auscultating for a bruit. However, the facility did not have physician's orders for the care of the AV fistula, and the resident's care plan did not specify the correct location of the fistula or the necessary care procedures. The facility's progress notes revealed that the resident's blood pressure was repeatedly taken from the left arm, where the AV fistula was located, contrary to the facility's policy. Additionally, the resident reported that the facility's nurses did not check the AV fistula site or the dressing, which was applied by the dialysis center staff. Interviews with the unit manager and the director of nursing confirmed that there should have been orders in place for monitoring and caring for the AV fistula site, which were not present, indicating a lapse in following professional standards of practice for dialysis care.
Failure to Assess Trauma History for Resident with PTSD
Penalty
Summary
The facility failed to assess a history of trauma and identify triggers to avoid potential re-traumatization for a resident with a known diagnosis of PTSD. The resident, who was admitted with diagnoses including dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history as part of the comprehensive assessment. The facility's policy on Trauma Informed Care, which requires identifying past trauma or adverse experiences, was not followed. The Social Service Evaluation did not reflect the PTSD diagnosis, and a trauma care plan was not initiated. Interviews with the social workers revealed gaps in the assessment process. Social Worker #1 acknowledged that the PTSD diagnosis was not included in the evaluation and that the resident should have been assessed for trauma history and triggers. Social Worker #2, who completed the evaluation, admitted to not reviewing the hospital discharge paperwork, which contained the PTSD diagnosis, as she considered it clinical information outside her purview. Additionally, she did not inquire about trauma history from the resident's family, despite the resident's request to leave the facility.
Failure to Act on Pharmacist's Recommendations for Lab Monitoring
Penalty
Summary
The facility failed to act upon the recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for a resident with a thyroid disorder. The resident was admitted in August 2022 and was receiving Levothyroxine, a hormone used to treat thyroid disorder. In January 2024, the Consultant Pharmacist recommended that a lab test be conducted to monitor the efficacy of Levothyroxine. However, the surveyor found that the recommendation was not documented in the resident's medical record, and the prescriber had not reviewed or acted upon it. Interviews with facility staff revealed that the Director of Nurses (DON) was responsible for distributing the pharmacist's recommendations to prescribers, but there was no evidence that the recommendations for this resident were reviewed. The prescriber response section on the recommendation form was left blank, indicating that the recommendation was not addressed. The Administrator acknowledged that the facility should have followed its policy to ensure pharmacy recommendations were reviewed and documented.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident who was admitted with a diagnosis of dementia and a known toothache. Upon admission, the resident's hospital discharge summary noted complaints of right lower tooth pain, dental caries, and an aphthous ulcer. The care plan included a referral to a dentist as needed. Despite frequent complaints of tooth pain documented in nursing progress notes, the facility did not arrange a timely dental appointment. The resident was given Tylenol, Orajel, and other pain management medications, but the dental referral remained pending. The Director of Nurses (DON) acknowledged that the in-house consultant dentist had no scheduled visit since the resident's admission, and the facility had not referred the resident to a community dentist until prompted by the surveyor's inquiry. The DON confirmed that a referral was sent to the in-house consultant dentist on a specific date, but there was no indication of when the dentist would visit. Consequently, the resident continued to experience pain without receiving the necessary dental evaluation and treatment in a timely manner.
Failure to Document Resident's Razor Burn and Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who developed redness and irritation on their facial area after being shaved by a staff member. The facility's policy requires documentation of all services provided, changes in condition, and incidents involving residents. However, there was no nursing documentation in the medical record related to the resident's razor burn, nor was there evidence that nursing staff assessed the razor burn or monitored its progress toward healing. The incident occurred when a CNA reported to a nurse that the resident had redness and irritation on their beard from shaving. The nurse assessed the resident's facial area, noted the redness, and notified the physician, who ordered the application of bacitracin to the affected area. Despite administering the treatment, the nurse failed to document the assessment, physician notification, or the new treatment order in the resident's medical record. Additionally, the nurse did not complete an incident report as required by the facility's policy. The Director of Nurses confirmed the lack of documentation in the resident's medical record, stating that nursing staff should have documented their assessments and any new treatment orders obtained from the physician. The absence of documentation indicates a failure to adhere to the facility's policies on charting and incident reporting, resulting in incomplete medical records for the resident.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
