Hadley Pointe Nursing Rehab & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Hadley, Massachusetts.
- Location
- 20 North Maple Street, Hadley, Massachusetts 01035
- CMS Provider Number
- 225697
- Inspections on file
- 26
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Hadley Pointe Nursing Rehab & Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia-related behavioral disturbance was sent to the ED after striking a CNA, and facility management decided at that time that the resident would not return. Although the facility’s policy required allowing residents to return from hospital, documenting unmet needs and attempts to meet them, and providing written notice of transfer/discharge, the resident’s status was changed from hospital leave bed-hold to discharged, despite appropriate bed availability and Medicaid bed-hold eligibility. The hospital CM reported multiple unsuccessful attempts to arrange the resident’s return while the resident was medically stable and cooperative, and the ombudsman and family members reported being told the facility would not readmit the resident, with no written notice or documented assessment showing why the resident’s needs could not be met.
A resident with encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering was transferred twice from the facility to the hospital, but the facility did not provide the required written notice of intent to transfer and/or discharge to the resident or the resident’s representative, nor did it send a copy of the notice to the State LTC Ombudsman as required by its own transfer/discharge policy. Review of the medical record showed no such documentation, and the Director of Social Services confirmed that no written notices or Ombudsman notifications could be produced.
Surveyors found that several resident rooms had PTAC units coated in dust and debris, and some walk-in shower room floors were heavily stained with a black substance. Facility staff acknowledged these unclean conditions, which did not support a safe, clean, or homelike environment for residents.
Two residents who were alert, oriented, and dependent on staff for care reported being treated in an undignified and disrespectful manner by a CNA during an overnight shift. Both described the CNA as abrupt, rude, and using profanity, with one resident also experiencing rough handling and ignored complaints of pain during care. These incidents were corroborated by a roommate and a nurse, and the CNA admitted to being agitated and not following proper procedures.
A resident who was cognitively intact and dependent on staff for ADLs reported being left in a soiled brief for several hours, but the allegation was not immediately reported to administration as required by policy. Additionally, an Activity Assistant was hired without the required Massachusetts NAR background check, as the HR representative was unaware of the requirement for all employees.
Two residents made allegations of abuse and mistreatment by a CNA, including rough handling, pain, and verbal abuse. The DON was notified of these allegations but did not report them to DPH within the required two-hour window, as confirmed by facility records and staff interviews.
The facility did not obtain or document a statement from a CNA accused of abuse after two separate residents made allegations against the same staff member on the same morning. Although the CNA was asked to leave the facility after the first allegation, leadership did not follow up to secure a statement or interview from the CNA regarding the second allegation, resulting in incomplete investigation documentation as required by policy.
A resident with limited lower extremity movement and total dependence on staff for ADLs experienced pain when a CNA repositioned them in bed without the required assistance from a second staff member, contrary to the individualized care plan. The CNA, aware of the two-person requirement, proceeded alone due to workload, resulting in the resident's complaint of pain and inconsistent adherence to care plan interventions.
Two CNAs did not receive required training on abuse, neglect, and exploitation during orientation, as mandated by federal regulations and facility policy. Personnel files lacked documentation of this education, and the administrator confirmed the absence of records supporting that the training was provided.
A resident with Parkinson's Disease and dementia was given Midodrine HCL for hypotension on multiple occasions when their systolic blood pressure was above the physician-ordered threshold. Nursing staff did not follow the order to hold the medication for elevated blood pressure, as documented in the MAR and confirmed by both a nurse and the DON.
Two residents in a memory care unit reported being inappropriately touched by a contracted podiatrist during routine foot care. Despite cognitive impairments, both residents consistently described the incidents to staff and police, indicating they were shocked and upset. The facility's policy prohibits such abuse, yet the podiatrist's actions violated this policy, resulting in a deficiency.
The facility failed to implement comprehensive abuse prevention policies for non-employee service providers, such as consultants and contractors. A podiatrist was not subjected to a Massachusetts Nurse Aide Registry check before providing services, and there was no evidence of annual abuse prohibition training. The facility's policies did not adequately address screening and training for these individuals, as confirmed by the administrator.
Two residents reported sexual abuse by a podiatrist, but the facility failed to report these allegations to the DPH within the required two-hour timeframe. The Director of Social Services promptly informed the DON, who delayed reporting due to the time taken to summarize and review the allegations with a supervisor, resulting in a report submission over four hours later.
The facility failed to notify the Physician/NP of significant weight loss for two residents, resulting in delayed treatment and inadequate monitoring. One resident experienced continued weight loss without timely notification to the Physician/NP or Legal Guardian, while another resident's weight loss was not communicated, leading to insufficient nutritional interventions. Staff interviews revealed inconsistencies in weight documentation and communication, contributing to the deficiencies.
Two residents experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident had a 7.8% weight loss over three months, with inadequate weight monitoring and delayed dietary interventions. Another resident experienced a 7.3% weight loss shortly after admission, with no re-weigh or timely assessment for interventions. The facility's inaction led to inadequate nutritional care for both residents.
The facility was unable to provide evidence of a written transfer agreement with a hospital certified by Medicare and Medicaid, necessary for timely resident hospital admissions. The Administrator initially claimed an agreement existed but could not locate it. The Corporate Nurse later provided a new agreement with a future effective date, indicating it was created after the surveyor's inquiry.
A resident's family reported persistent issues with missing clothing, attributed to an external laundry service, but the facility failed to document and resolve the grievance. Despite being aware of the issue, the social worker did not formally record or investigate the complaints, and the grievance was not reviewed by the administrator due to lack of documentation.
Two residents in an LTC facility did not receive necessary grooming assistance, despite being dependent on staff for personal hygiene. One resident, with severe cognitive impairment, was observed unshaven over several days, contrary to their preference. Another resident, moderately cognitively impaired, also remained unshaven despite expressing a preference for being clean-shaven. Staff interviews confirmed that grooming was not consistently offered, and the unit manager acknowledged ongoing issues with grooming care.
The facility failed to ensure required physician visits for two residents, resulting in a deficiency. One resident with dementia and another with Alzheimer's disease were last seen by a physician in July 2024, with subsequent visits conducted only by an NP. The NP stated that routine visits were scheduled through the physician's office, and she had been informed that NPs could complete all routine visits. The corporate nurse confirmed the regulation of alternating 60-day visits between physicians and NPs, but records showed non-compliance.
The facility failed to effectively address the issue of residents' clothing going missing after being laundered by an outside company. Despite numerous grievances and a QAPI project, the facility did not analyze the root cause or implement measures to prevent recurrence. Residents and families expressed ongoing frustration, and the facility lacked a system to track laundry items or evaluate the effectiveness of their improvement plan.
The facility failed to conduct required COVID-19 testing every 48 hours during an outbreak on the [NAME] Nursing Unit, as per state guidelines. Additionally, the code carts, including emergency equipment like the AED, were found covered in dust, indicating a lapse in cleaning protocols. These deficiencies highlight issues in infection control and equipment maintenance.
The facility failed to provide a dignified dining experience for two residents. One resident, with severe cognitive impairment, was left with a meal tray out of reach for 22 minutes before assistance was provided. Another resident had their meal interrupted for wound care and was not offered additional food upon return. Staff acknowledged issues with meal tray delivery and recurring meal interruptions due to wound rounds.
A resident with severe cognitive impairment was administered Mirtazapine without informed consent from their legal guardian. The facility initiated the medication to address weight loss, but failed to secure the necessary consent, violating the resident's rights. The guardian was contacted after the medication had already been administered, and did not consent to its use.
The facility failed to maintain a homelike environment by mismanaging residents' personal clothing. A resident with dementia reported frequent loss of clothing, often replaced with items from other residents. Another resident's family member noted persistent issues with missing clothing laundered by an outside contractor, leading to frequent replacements. The facility lacked a system to track clothing, and staff confirmed delays in returns.
A resident experienced a decline in ADLs and developed an unstageable pressure injury, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. The MDS Nurse recognized the decline was not self-limiting and required intervention, yet the necessary assessment was not conducted, resulting in a deficiency.
A facility failed to complete a Level I PASRR screening for a resident prior to admission, resulting in the resident being admitted without determining the need for further evaluation for ID/DD or SMI. The resident had diagnoses including Bipolar Disorder and Dementia. The social worker responsible for PASRR screenings was unavailable at the time, and the screening was completed only after admission, despite reminders to staff about the requirement.
A facility failed to update a resident's care plan after a significant change in condition following a fall with a hip fracture. Despite a comprehensive assessment indicating increased care needs, the interdisciplinary team did not hold a care plan meeting to revise the plan, as required by policy. The resident, who was severely cognitively impaired, experienced weight loss and pain, and the legal guardian was not involved in a care plan meeting post-assessment.
A facility failed to maintain ongoing communication with a dialysis center for a resident requiring hemodialysis. Despite policy requirements for regular updates, the facility did not send necessary information on multiple occasions. Staff confirmed the oversight, which could affect the resident's care.
A facility failed to administer an Influenza vaccine to a resident with severe cognitive impairment due to not obtaining consent or providing education to the invoked Health Care Proxy (HCP). The resident's medical record lacked documentation of consent and education, and the Vaccine Consent Form was incomplete. The Unit Manager confirmed these oversights, which were contrary to the facility's policy and CDC guidelines.
A facility failed to reassess bed safety for a resident after changing from an air mattress to a foam mattress, as required by their policy. The resident, with limited mobility and using bilateral side rails, was at risk of entrapment. The Maintenance Director confirmed that no new assessment was conducted, despite the facility's policy mandating inspections with any change in bed components.
A resident with multiple diagnoses was found with a dressing on their heel concealing a suspected DTI, with no documentation of the wound's discovery or treatment orders. Staff interviews revealed a lack of awareness and documentation, and the facility's investigation could not determine who applied the dressing.
A resident with a history of falls and requiring assistance was left unattended by a CNA while standing with a walker in the bathroom. The resident fell, sustaining a fractured scapula and other injuries, and was transferred to the hospital. The facility's falls management policy was not followed, and inconsistencies were found in the CNA's account of the incident.
Failure to Readmit Hospitalized Resident and Provide Required Transfer/Discharge Protections
Penalty
Summary
The deficiency involves the facility’s failure to allow a severely cognitively impaired resident to return following a hospital transfer and its decision to treat the resident as discharged at the time of transfer, contrary to its own transfer/discharge policy and resident rights. The facility’s written policy stated that residents sent to an acute care setting, such as a hospital, must be permitted to return, and that a determination that needs could not be met must be based on an assessment at the time of proposed return, with documentation of unmet needs, attempts to meet those needs, and any danger posed to others. The policy also required written notice to the resident and representative of the transfer or discharge and the reasons for the move, as well as application of bed-hold and return policies to all residents regardless of payor source. The resident had diagnoses including encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering, and was assessed as severely cognitively impaired, requiring supervision for basic ADLs. After the resident hit a CNA on the head and neck, management and a nurse decided to send the resident to the ED for evaluation and possible referral to a different facility, and the resident was transferred to the hospital. The business office manager reported that the resident, whose primary payor was Medicaid and who was eligible for a 20‑day bed hold, was initially placed on a hospital leave bed hold but was then changed to discharged effective the date of transfer. Bed availability records showed that a gender‑specific bed appropriate for the resident was available on multiple days following the transfer. The hospital case manager reported that the resident remained hospitalized for an extended period and that the hospital contacted the facility multiple times regarding the resident’s return once medically ready, but the facility either refused readmission or did not respond, despite the resident being medically stable and cooperative with care. The ombudsman and family members reported being told by the facility or hospital that the facility would not readmit the resident, and both family members stated they did not receive any written notification of transfer or discharge or an explanation of why the facility could not meet the resident’s needs. The director of social services and the administrator were unable to provide documentation showing which of the resident’s needs could not be met, what attempts had been made to meet those needs, or any written notice to the resident’s health care agents, despite the administrator stating that the interdisciplinary team had decided the resident could not return.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer and/or discharge to a resident, the resident’s representative, and the State Long-Term Care Ombudsman. The facility’s own “Resident Transfer and Discharge Policy and Procedure” (dated 2025) requires that, before any transfer or discharge, the facility must notify the resident and resident representative in writing, in a language and manner they understand, and must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman while maintaining evidence that the notice was sent. The policy also specifies that the written notice must include the reasons for the move, a statement of the resident’s appeal rights, the name, mailing and email address, and telephone number of the entity that receives appeal requests, information on how to obtain and complete an appeal form, and the name, address, and telephone number of the Ombudsman. The policy allows notice to be made as soon as practicable when an immediate transfer or discharge is required by urgent medical needs. Resident #2 was admitted in November 2025 with diagnoses including encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering. Nursing progress notes showed that this resident was transferred from the facility and admitted to the hospital on two occasions, on [DATE] and again on 12/15/25. Review of the medical record revealed no documentation that the facility provided written notification of the transfer and/or discharge to the resident or the resident’s representative, and no documentation that a copy of such notice was sent to the State Long-Term Care Ombudsman for the transfers occurring on 11/26/25 and 12/15/25. In an interview on 01/20/26 at 4:05 P.M., the Director of Social Services confirmed she could not provide any documentation to support that the required written notifications or Ombudsman copies had been provided for these transfers.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on one of two resident units. During an environmental tour, multiple resident rooms were found to have PTAC (packaged terminal air conditioner) units that were heavily coated in dust and debris, with both the tops and front ventilation grilles affected. Additionally, walk-in shower room floor tiles in some rooms were heavily stained with a black substance, indicating a lack of cleanliness. These conditions were documented through direct observation and photographs. Interviews with facility staff, including the Director of Maintenance and the Administrator, confirmed the surveyor's findings. Both acknowledged that the rooms were not homelike and that the PTAC units and bathroom floors required thorough cleaning. The facility's own policy on environmental services inspection requires regular assessment and maintenance of a safe and sanitary environment, which was not upheld in these instances.
Failure to Provide Dignified and Respectful Care During Overnight Shift
Penalty
Summary
Two residents who were alert, oriented, and dependent on staff for care reported being treated in an undignified and disrespectful manner by a Certified Nurse Aide (CNA) during the overnight shift. Facility policy requires that residents be treated with respect and dignity, but both residents described the CNA as abrupt, rude, and failing to respect their wishes. One resident, with diagnoses including acute bronchitis and moderate dementia, alleged that the CNA used profanity and was rough during care, which was corroborated by the resident's cognitively intact roommate who overheard the incident and reported similar language and behavior. Another resident, with a history of osteoarthritis, chronic pain syndrome, diabetes, and major depressive disorder, was also dependent on staff for all activities of daily living and mobility. This resident reported that the CNA entered the room without explanation, began care abruptly, and ignored complaints of pain when moving the resident's leg, despite the care plan requiring assistance from two staff members for bed mobility. The CNA admitted to being agitated and acknowledged not following proper procedures, including attempting to move the resident alone and continuing care despite the resident's expressed pain. Interviews with the involved residents, a roommate, and a nurse confirmed that the CNA used harsh language, failed to communicate appropriately, and did not provide care in a manner that maintained the residents' dignity or respected their individual needs. The incidents were reported to nursing staff immediately after they occurred, and the facility's investigation documented the residents' accounts and the CNA's admission of inappropriate conduct.
Failure to Follow Abuse Reporting Policy and Conduct Required Background Checks
Penalty
Summary
The facility failed to implement and follow its abuse policy in two key areas. First, when a resident who was cognitively intact and required substantial assistance with activities of daily living reported being left in a soiled incontinence brief for three hours after requesting help from a CNA, the staff member who assisted the resident in writing a complaint did not immediately report the allegation to the Administrator or Director of Nursing as required by facility policy. The Administrator only became aware of the incident three days later when he found the resident's written statement under his door, at which point the incident was reported to the Department of Public Health. Second, the facility did not conduct a required Massachusetts Nurse Aide Registry (NAR) background check for an Activity Assistant upon hire. The personnel file for the Activity Assistant lacked documentation of the NAR check, and the Human Resources representative stated that he was unaware that NAR checks were required for all potential employees, not just nurses and CNAs. The Administrator confirmed that there was no evidence of an NAR check for this employee.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse allegations involving two residents and a certified nurse aide (CNA) to the Department of Public Health (DPH) within the required two-hour timeframe. According to facility policy, any report of suspected or alleged abuse must be reported to the appropriate authorities not later than two hours after the allegation is made. On 08/17/25, the Director of Nursing (DON) was notified at 5:50 A.M. of an allegation by one resident that a CNA was rough during incontinence care, causing pain and yelling at the resident. The facility submitted the report to DPH at 10:08 A.M., exceeding the two-hour reporting requirement. A second allegation involving the same CNA and another resident, who reported being subjected to profanity during care, was also not reported within the required timeframe, with the report submitted the following day at 6:54 P.M. Interviews with facility staff confirmed that the DON was made aware of both allegations in the early morning hours, but the reports were not submitted to DPH as required by policy. The administrator stated that staff are expected to report abuse allegations immediately to administration, and that administration must then report to DPH within two hours. The investigation summaries and reporting system records corroborate that the facility did not meet the mandated reporting timelines for both incidents.
Failure to Obtain and Document Accused Staff Statement in Abuse Investigations
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and documented after being made aware of two separate allegations of resident abuse by the same Certified Nurse Aide (CNA). On the morning in question, the first allegation involved a resident reporting that the CNA directed profanity at them during care, with the incident witnessed by the resident's roommate. The facility's policy required that an initial investigation be initiated within 24 hours, including documentation of witness interviews. However, there was no documentation that the accused CNA was interviewed or that a written witness statement was obtained regarding the first allegation. Shortly after the first report, a second allegation of abuse involving the same CNA and another resident was made. At this point, the CNA had already been instructed to leave the facility pending investigation. Despite being notified of the second allegation, facility leadership did not reach out to the CNA for a statement or interview regarding the second incident. Interviews with staff and review of records confirmed that no documentation existed to show that the accused CNA was interviewed about the second allegation, as required by facility policy.
Failure to Follow Care Plan for Bed Mobility Assistance
Penalty
Summary
A deficiency occurred when staff failed to consistently implement and follow a resident's care plan interventions related to bed mobility. The resident, who had limited movement in both lower extremities and was totally dependent on staff for activities of daily living and mobility, required assistance from two staff members for bed mobility and positioning, as documented in the care plan. On one occasion during the overnight shift, a CNA provided incontinence care and repositioned the resident in bed without the required assistance from a second staff member. The CNA took hold of the resident's left leg, rolled the resident onto their side, and caused pain in the left hip, despite the resident's verbal request to stop due to pain. The resident reported that staff did not consistently provide the required two-person assistance for bed mobility and that the CNA was not gentle during care. The CNA acknowledged awareness of the care plan requirement but proceeded alone due to being too busy to get help, believing the resident could assist. The incident was reported, and interviews confirmed that the care plan was accessible to staff and specified the need for two-person assistance, which was not followed during the incident.
Failure to Provide Required Abuse Prohibition Training During Orientation
Penalty
Summary
The facility failed to ensure that two certified nurse aides received required training on the prohibition of abuse, neglect, exploitation, and misappropriation of resident property during their orientation, as mandated by federal regulations and the facility's own Abuse Prohibition Policy. Review of personnel files for both aides showed no documentation of such training at the time of their hire. The facility's policy specifies that this education must be provided to all employees at orientation and at least annually. During an interview, the administrator confirmed that there was no documentation to support that the two aides had received the required abuse prohibition education during orientation.
Failure to Follow Physician's Order for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident with Parkinson's Disease and dementia, who was prescribed Midodrine HCL for hypotension, was free from significant medication errors. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 115 or diastolic pressure was greater than 80. Despite this, nursing staff administered Midodrine on multiple occasions when the resident's SBP exceeded the prescribed threshold, as documented in the Medication Administration Record (MAR) for May 2025. Nursing documentation showed that the medication was given at least eleven times when the resident's SBP was above 115, contrary to the physician's order. During interviews, both a nurse and the Director of Nursing acknowledged that the medication should not have been administered under these circumstances. The facility's policy required staff to verify medication orders and obtain vital signs as necessary, but these procedures were not followed, resulting in the administration of medication outside the prescribed parameters.
Failure to Protect Residents from Abuse by Contracted Podiatrist
Penalty
Summary
The facility failed to protect two residents from physical abuse by a contracted podiatrist, who engaged in unwanted and inappropriate physical contact. Both residents, despite being cognitively impaired, were able to communicate their experiences to the staff and police. The incidents involved the podiatrist touching the residents in a sexually inappropriate manner during routine podiatry services. The residents consistently reported the incidents, indicating they were shocked and upset by the podiatrist's actions. Resident #2, who was severely cognitively impaired, reported to a CNA that the podiatrist grabbed their breasts after a podiatry session. The resident's account was consistent across interviews with facility staff and the police. The police report confirmed that Resident #2 was visibly upset when recounting the incident. Similarly, Resident #1, who was moderately cognitively impaired, reported that the podiatrist put his hands down their shirt and touched their breasts. This resident also provided a consistent account to the Director of Rehabilitation and the police, describing the podiatrist's inappropriate behavior. The facility's policy on abuse prohibition clearly states that all forms of abuse, including sexual abuse, are prohibited. However, the podiatrist's actions violated this policy, resulting in a deficiency. The Director of Social Services noted that despite the residents' cognitive impairments, their accounts were consistent and credible. The facility's failure to prevent these incidents highlights a significant lapse in ensuring the safety and protection of its residents from abuse by contracted healthcare providers.
Deficiency in Abuse Prevention Policies for Non-Employee Service Providers
Penalty
Summary
The facility failed to ensure that their abuse prevention policies were comprehensive and effectively implemented, particularly concerning the screening and training of consultants, contractors, volunteers, caregivers, and students. The facility's policy on Abuse Prohibition, revised on 10/24/22, outlined the screening process for potential employees but did not extend these requirements to other individuals providing services at the facility. Specifically, there was no documentation indicating that the facility conducted a Massachusetts Nurse Aide Registry (NAR) check on a consultant podiatrist before he began providing services. Additionally, the policy did not specify how abuse prohibition training would be provided to non-employee service providers. The facility's Consultant Agreements and Responsibilities policy, revised on 03/01/22, also lacked provisions for screening and training related to abuse prevention for consultants and other non-employee service providers. A review of the podiatrist's training transcript revealed no evidence of annual training on abuse prohibition and reporting obligations. During an interview, the facility's administrator confirmed the absence of documentation for the NAR check and the required training for the podiatrist, highlighting a significant oversight in the facility's compliance with abuse prevention protocols.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse within the required two-hour timeframe as mandated by their policy. On January 2, 2025, two residents reported inappropriate touching by a podiatrist after receiving foot care. The Director of Social Services was informed of these allegations around 1:00 P.M. and 1:30 P.M., respectively, and promptly notified the Director of Nurses (DON). However, the DON did not report these allegations to the Department of Public Health (DPH) until over four hours later, at approximately 5:49 P.M. and 5:52 P.M. The delay in reporting was attributed to the time taken by the DON to summarize and review the allegations with her Corporate Clinical Supervisor. Despite being aware of the allegations by approximately 1:45 P.M., the DON did not adhere to the facility's policy, which requires immediate reporting of such incidents to the appropriate authorities within two hours. This inaction resulted in a failure to comply with the mandated reporting timeframe, as outlined in the facility's Abuse Prohibition policy.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician/Nurse Practitioner (NP) of changes in condition for two residents, leading to inadequate treatment and monitoring. For one resident, the facility staff did not timely notify the Physician/NP of significant weight loss, resulting in delayed treatment and continued weight loss. Additionally, the resident's Legal Guardian was not informed of a change in treatment related to the weight loss before initiating medication that required consent. The resident experienced a significant weight loss over several months, and the facility did not document weights for certain months, nor did they notify the Physician/NP of the dietician's recommendations. Another resident was admitted with several diagnoses, including Alzheimer's Disease and Major Depressive Disorder. The facility failed to notify the Physician/NP of significant weight loss identified through weekly weights, resulting in inadequate treatment and monitoring of the resident's nutritional status. The resident's weight was not consistently documented, and there were no active orders for ongoing weights after the initial four weeks. The facility did not notify the Physician/NP or dietician of the significant weight loss, which was identified during the survey. Interviews with staff revealed that the facility's process for obtaining and documenting weights was inconsistent, and there was a lack of communication regarding significant weight changes. The NP and dietician were not informed of the residents' weight loss in a timely manner, preventing them from implementing appropriate interventions. The facility's failure to follow its policies on weight monitoring and notification of changes in condition contributed to the deficiencies identified during the survey.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents, leading to significant weight loss and inadequate monitoring of their nutritional needs. Resident #65 experienced a 7.8% weight loss over three months, which was not addressed with effective interventions. The facility did not adhere to physician orders for monthly weight monitoring and failed to implement and monitor weekly weights after the resident was hospitalized and readmitted. Dietary interventions were not timely implemented, and meal and dietary supplement intakes were inadequately monitored. Resident #65's clinical record showed no evidence of reassessment by the dietician between the identification of significant weight loss and the resident's hospitalization. After readmission, weekly weight monitoring was not implemented as required. The resident's nutrition care plan was not updated with new interventions, and there was a delay in ordering house supplements. The resident's significant weight loss was not evaluated by the nurse practitioner, and meal intake percentages were inconsistently recorded. Resident #85 also experienced significant weight loss, with a 7.3% decrease in less than 30 days after admission. The facility did not obtain a re-weigh to validate the accuracy of the weight and failed to assess the resident to determine if interventions were needed. The nutrition care plan for Resident #85 was initiated after the weight loss was identified, but there was no evidence of timely intervention or monitoring to address the nutritional risk related to the resident's medical conditions.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to provide evidence of a written transfer agreement with a hospital certified by Medicare and Medicaid, which is necessary to ensure timely and appropriate hospital admissions for residents. During an interview, the Administrator claimed that a written transfer agreement existed with an area hospital but was unable to locate it. Later, the Corporate Nurse provided a copy of a transfer agreement, but it was noted that the effective date was set for a future date, indicating that the agreement was created after the surveyor's inquiry. Both the facility and the hospital were unable to locate any existing written transfer agreement prior to the surveyor's request, leading to the creation of a new agreement effective from a future date.
Failure to Resolve Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident, as evidenced by the lack of documentation and initiation of the grievance process regarding missing clothing. The resident, who was admitted in July 2021, had diagnoses of Anxiety Disorder, Dementia, and Depression, and was severely cognitively impaired with a BIMS score of three out of 15. The resident's family member repeatedly reported missing clothing to the facility staff, who attributed the issue to the use of an external laundry service, making it difficult to trace the clothing. Despite being aware of the family's concerns, the social worker did not document these as formal grievances, nor did he investigate or follow up for resolution. The grievance binder lacked any record of the family's complaints, and the administrator confirmed that the grievance would have been reviewed if it had been documented. This oversight resulted in the facility's failure to act promptly on the grievances, as required by their policy on resident rights.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents, resulting in deficiencies in personal hygiene care. Resident #59, who was admitted with conditions such as unspecified dementia and severe cognitive impairment, required maximum assistance for personal hygiene. Despite this, the resident was observed multiple times over several days with unshaven facial hair, which was against their personal preference. Family members and staff confirmed that the resident was unable to shave independently and required staff assistance, which was not consistently provided. Similarly, Resident #33, who was moderately cognitively impaired and had a history of refusing care, also did not receive adequate grooming assistance. The resident expressed a preference for being clean-shaven, yet was observed with significant facial hair over several days. The resident's healthcare proxy had specifically requested shaving assistance for a family visit, which was not fulfilled, leading to dissatisfaction. Staff interviews revealed that grooming was not consistently offered, and the resident did not always request it, despite agreeing to it when offered. The unit manager acknowledged that grooming and shaving were ongoing issues affecting not only these two residents but others as well. Staff were equipped with the necessary tools for grooming, yet the deficiency persisted, indicating a systemic issue in providing consistent personal hygiene care. The lack of regular grooming assistance for residents who were dependent on staff for such needs highlights a significant lapse in the facility's care practices.
Failure to Provide Required Physician Visits
Penalty
Summary
The facility failed to provide physician visits at the required frequency for two residents, resulting in a deficiency. Resident #65, admitted in July 2022 with dementia, was last seen by a physician on July 17, 2024. Subsequent visits were conducted by a nurse practitioner (NP) on multiple occasions, but there was no evidence of an alternating 60-day visit by a physician since July 17, 2024. Similarly, Resident #79, admitted in February 2024 with Alzheimer's disease, was last seen by a physician on July 17, 2024, and has only been seen by the NP for routine visits since then, without any alternating 60-day physician visits. During interviews, the NP stated that all routine visits were scheduled through the physician's office, and she had been informed in October 2024 that NPs could complete all routine rounding visits. The NP indicated that she had been conducting all routine visits for her assigned residents since this change. The corporate nurse confirmed that the facility followed regulations requiring physician visits every 60 days, which could alternate between the physician and the NP. However, the records showed a lack of compliance with the alternating visit requirement, leading to the deficiency.
Deficiency in Addressing Missing Clothing Items
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) system to address the issue of residents' clothing consistently going missing after being sent to an outside contracted laundry service. The facility's policy on QAPI, revised in October 2022, emphasized the importance of data-driven decision-making and ongoing monitoring through an interdisciplinary team. However, the Performance Improvement Project (PIP) related to missing clothing items lacked a thorough analysis of the root cause, actions to prevent recurrence, and mechanisms for feedback from staff or residents. Throughout the year, the facility documented numerous grievances related to missing clothing, with 13 to 17 items reported missing each quarter. Despite these grievances, the facility did not implement effective measures to resolve the issue, such as tracking systems for laundry items or providing education to staff and residents. Interviews with family members and residents revealed ongoing frustration, as they frequently had to replace missing clothing items, and their concerns were not formally documented or addressed by the facility's social worker. The facility administrator acknowledged the initiation of a QAPI project due to the growing concern over missing personal items but admitted to being unaware of the lack of formal grievance documentation by the social worker. The administrator also noted the absence of a system to evaluate the effectiveness of the PIP or to track the personal laundry items sent out and returned. This deficiency highlights the facility's failure to adequately address and resolve the issue of missing clothing, leading to continued dissatisfaction among residents and their families.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to infection control practices during a COVID-19 outbreak on the [NAME] Nursing Unit. Despite a staff member testing positive for COVID-19 on 1/10/24, the facility did not conduct the required testing of residents every 48 hours. Residents were tested on 1/11/24 and 1/13/24, but not on 1/15/24, as the Corporate Nurse deemed it unnecessary. This decision was contrary to the Massachusetts Department of Public Health guidelines, which mandate testing every 48 hours during an outbreak until no new cases are identified for seven days. An additional staff member tested positive on 1/15/25, indicating ongoing transmission risk. Additionally, the facility failed to maintain the code carts in a clean and sanitary manner. Observations on 1/15/24 revealed that the AED and other emergency equipment on the code cart were covered with a thick layer of gray dust. Both Nurse #1 and Nurse #2 acknowledged that the equipment should not be dusty and that the code cart is supposed to be checked and cleaned every night shift. The presence of dust on emergency equipment suggests a lapse in routine cleaning protocols, potentially compromising the readiness and safety of life-saving equipment.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, resulting in deficiencies in their care. Resident #85, who has severe cognitive impairment and requires assistance with eating, was left with a tray of food placed out of reach for an extended period. The resident sat watching others eat while waiting for assistance, which was not provided until 22 minutes later. Staff acknowledged the issue, citing inconsistencies in meal tray delivery as a contributing factor. Resident #59, also with severe cognitive impairment and dependent on staff for eating, had their meal interrupted for wound care. The resident was removed from the dining area before finishing their breakfast, and upon return, no additional food or reheating of the meal was offered. Staff admitted that meal interruptions due to wound rounds were a recurring issue, and the resident's uneaten meal was only noticed after the surveyor's intervention. Both incidents highlight the facility's failure to uphold resident rights to a dignified dining experience. The staff's actions and inactions led to residents being unable to enjoy their meals properly, with one resident missing a meal entirely due to procedural disruptions. These deficiencies were observed and confirmed through interviews with staff and direct observation by the surveyor.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to uphold the rights of a resident's legal representative by administering a new medication, Mirtazapine, without obtaining informed consent from the resident's court-appointed legal guardian. The resident, who was severely cognitively impaired and had been deemed incapacitated by the court, was given Mirtazapine as an appetite stimulant due to significant weight loss. However, the facility did not secure the necessary consent from the legal guardian before starting the medication. The facility's policy on resident rights requires that residents and their representatives be informed and able to exercise their rights, which was not adhered to in this case. The medication was administered for several days before the legal guardian was contacted via email, and even after the guardian did not consent, the medication continued to be administered. The legal guardian expressed confusion and concern over the lack of discussion regarding non-pharmacological interventions before resorting to medication.
Facility Fails to Manage Residents' Personal Clothing
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents, resulting in the loss and mismanagement of personal clothing. Resident #3, who was admitted with dementia and depression, reported that their clothing frequently went missing and was often replaced with clothing belonging to other residents. This issue was observed during an interview where the resident expressed concern over the loss of personal items, which were sometimes located by staff but often not returned. Similarly, Resident #32, who was severely cognitively impaired, experienced persistent issues with missing clothing. The resident's family member reported that clothing was frequently lost after being laundered by an outside contractor, necessitating frequent replacements. This concern was echoed by other residents during a council meeting, where all attendees reported similar issues with missing clothing. The facility administrator acknowledged the problem, noting the lack of a system to track clothing sent to and returned from the laundry service. Staff interviews confirmed the ongoing issue, with reports of significant delays in the return of clothing items.
Failure to Complete SCSA for Resident with Decline in ADLs and Skin Condition
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a decline in activities of daily living (ADLs) and skin condition. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required when there is a major decline or improvement in a resident's status that impacts more than one area of health and requires interdisciplinary review. The resident in question, admitted with diagnoses including unspecified dementia and type 2 diabetes, showed a significant decline in their ability to perform ADLs and developed an unstageable pressure injury, which was not present in the previous assessment. The MDS Nurse acknowledged that the resident's decline was not self-limiting and would not resolve without staff intervention, indicating that an SCSA should have been completed. The resident's most recent quarterly MDS assessment showed increased dependency on staff for upper body dressing, personal hygiene, bed mobility, and ambulation, compared to the prior assessment. Despite these changes, the necessary SCSA was not conducted, leading to the deficiency noted in the report.
Failure to Complete Timely PASRR Screening for Resident
Penalty
Summary
The facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident prior to their admission. This oversight resulted in the resident being admitted without a determination of whether they screened positive for intellectual disability (ID), developmental disability (DD), or serious mental illness (SMI) that would require further evaluation. The resident, who was admitted in December 2024, had diagnoses including Bipolar Disorder, Depression, Anxiety Disorder, and Dementia. However, their clinical record lacked evidence of a completed Level I PASRR. During interviews, it was revealed that the social worker responsible for completing the PASRR screenings was unavailable at the time of the resident's admission. The social worker acknowledged that this was not the first instance of such an oversight occurring when she was unavailable. Despite reminders to other staff about the requirement for preadmission screening, the Level I PASRR for the resident was only completed after their admission, highlighting a lapse in the facility's adherence to its policy on preadmission screening for mental disorders and intellectual disabilities.
Failure to Revise Care Plan After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to review and revise the care plan for a resident following a significant change in condition, as required by their policy. The resident, who was admitted with diagnoses including dementia and hypothyroidism, experienced a fall resulting in a hip fracture, which constituted a significant change in condition. Despite the completion of a comprehensive assessment for significant change in status (SCSA), the interdisciplinary team (IDT) did not hold a care plan meeting to update the resident's care plan. The facility's policy mandates that care plans be reviewed and revised after each assessment, including significant changes, to reflect the resident's changing needs and goals. Observations and interviews revealed that the resident, who was severely cognitively impaired, required increased assistance with daily activities and experienced weight loss and pain following the fall. The resident's legal guardian was not involved in a care plan meeting after the SCSA, and the social worker acknowledged that the IDT did not meet to revise the care plan post-SCSA, citing a recent meeting as the reason. However, the resident's condition had changed significantly since the last meeting, indicating a failure to adhere to the facility's policy for care plan updates.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not maintain ongoing communication and documentation with the dialysis center for a resident who was admitted with diagnoses including repeated falls, vascular dementia, and chronic kidney disease stage 4. The facility's policy required ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis care and services, which was not adhered to. The deficiency was identified through a review of the resident's communication binder, which showed that the facility did not communicate any information to the dialysis center on multiple specified dates. Interviews with facility staff confirmed that the facility was responsible for sending updated information to the dialysis center on designated days, but failed to complete the dialysis communication sheet as required. This lack of communication could potentially impact the resident's care and treatment outcomes.
Failure to Administer Influenza Vaccine Due to Lack of Consent and Education
Penalty
Summary
The facility failed to ensure that an Influenza vaccine was administered to a resident who was unable to make medical decisions due to severe cognitive impairment. The resident's Health Care Proxy (HCP) was invoked, but the facility did not obtain consent or provide education to the HCP regarding the vaccination. The facility's policy required obtaining consent and providing education, but these steps were not documented in the resident's medical record. The Vaccine Consent Form was undated and incomplete, and there was no evidence of education on the risks and benefits of the vaccination provided to the HCP. The resident, who was admitted with diagnoses including Repeated Falls, Vascular Dementia, and Chronic Kidney Disease Stage 4, was identified as lacking capacity to make healthcare decisions. Despite the family declining the Influenza vaccine, there was no documentation of education being provided. The Unit Manager confirmed the absence of written consent and education, acknowledging that the facility should have obtained these. The resident's January 2025 Physician orders did not include an order for the Influenza vaccination, further indicating the oversight in following the facility's policy and CDC guidelines.
Failure to Reassess Bed Safety After Mattress Change
Penalty
Summary
The facility failed to conduct a necessary inspection of bed rails and mattresses for a resident, identified as Resident #292, who was at risk of entrapment due to a change in the mattress type. The resident, who had limited mobility and utilized bilateral side rails, was admitted with diagnoses including fractures of the left radius and ulna, and dementia. The resident's care plan included the use of a pressure redistribution mattress and bilateral quarter side rails for support, initiated due to the resident's wrist fracture and limited mobility. The deficiency was identified when the surveyor observed that the resident's bed had a foam mattress instead of the previously assessed air mattress. The facility's policy required inspections of bed frames, mattresses, and bed rails whenever there was a change in these components. However, the Maintenance Director confirmed that no new assessment was conducted after the foam mattress was installed, which was a deviation from the facility's policy. The Maintenance Director acknowledged that a Bed Device Test should have been completed to evaluate the safety of the new bed configuration, but it was not done. This oversight placed the resident at risk for possible entrapment, as the bed system was not reassessed for safety following the change in mattress type. The lack of documentation and evaluation of the new bed frame and mattress combination highlighted the facility's failure to adhere to its own bed safety protocols.
Failure to Document and Report Deep Tissue Injury
Penalty
Summary
The facility failed to provide nursing care and treatment that met professional standards of quality for a resident who was found with a dressing on their right heel, concealing a suspected deep tissue injury (DTI). There was no nursing documentation to support when the wound was initially found, who applied the dressing, or what treatment orders were obtained from the provider. The facility's policy required prompt notification of changes in skin condition, complete wound evaluation upon new in-house acquired wounds, and obtaining wound care orders, none of which were documented in this case. The resident, who had diagnoses including Parkinson's disease, type II diabetes, dementia, and a history of falls, was admitted to the facility in February 2024. On a specific date, the wound care nurse discovered the DTI while providing care and noted that the dressing was dated two days prior, but lacked nursing initials and documentation in the medical record. Interviews with staff revealed that none were aware of the pressure area or the dressing being applied, and a nurse who completed a skin assessment the day after the dressing was dated did not recall a dressing being present. The Director of Nursing confirmed the absence of documentation regarding the pressure injury in the resident's medical record and stated that the nursing staff did not follow the facility's Skin Integrity and Wound Management Policy. The facility's investigation was unable to determine which staff member placed the dressing, and a facility-wide assessment of all residents' skin was conducted following the incident.
Resident Left Unattended, Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was assessed as being at risk for falls. The resident, who had a history of falls, gait abnormalities, muscle weakness, and dementia, required assistance from one staff member for toileting, transfers, and mobility. On the day of the incident, a Certified Nurse Aide (CNA) left the resident unsupervised and unattended while standing with a walker in the bathroom. This action was contrary to the resident's care plan, which required staff to provide extensive assistance for transfers and moderate assistance for toileting. The incident occurred when the CNA left the resident standing in the bathroom doorway to retrieve a recliner chair from the hallway. During this time, the resident fell backwards, sustaining a fractured left scapula, a right elbow skin tear, and a small cut on the right eyebrow. The resident was subsequently transferred to the hospital emergency department for treatment. The facility's policy on falls management, which required staff to implement strategies to minimize fall risks, was not adhered to in this instance. Interviews conducted during the investigation revealed inconsistencies in the CNA's account of the incident. The CNA acknowledged being aware of the resident's fall risk and admitted to leaving the resident unattended. Another CNA confirmed that the resident required assistance with all activities of daily living and should not have been left alone. The facility administrator noted discrepancies in the CNA's statements regarding her actions at the time of the fall, confirming that the resident was left unattended, leading to the fall and subsequent injuries.
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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