Haverhill Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 126 Monument Street, Haverhill, Massachusetts 01832
- CMS Provider Number
- 225290
- Inspections on file
- 23
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Haverhill Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain an effective system to track or measure the performance of its QAPI program, as required by its own policy. QAPI meeting minutes showed discussions on antipsychotic use, pharmacy, maintenance, and falls, but lacked documentation of measurable outcomes or tracking of progress. The Administrator and DON could not specify compliance or target goals for identified issues.
The facility did not fully document infection surveillance data, leaving key information such as signs and symptoms and causative organisms incomplete for multiple infections over several months. The Infection Preventionist confirmed that outcomes of treatment were not tracked and trends were not analyzed to identify possible sources or patterns of infection spread, despite facility policy and national standards requiring comprehensive infection control practices.
The facility did not follow its policy for antibiotic stewardship, as 77 antibiotics prescribed over three months were not reviewed for appropriateness or efficacy within the recommended 48-72 hours. The Infection Preventionist confirmed that follow-up reviews with providers were not conducted after antibiotic initiation, and reviews only occurred during monthly line listing checks.
Two residents did not receive appropriate care planning and interventions: one with substance use disorder did not have a care plan addressing their alcohol and opioid abuse, and another with multiple chronic conditions did not have physician-ordered geri-sleeves applied to their arms and legs, with no documentation of refusal and staff unaware of the order.
The facility did not respond to or resolve concerns repeatedly raised by residents in monthly council meetings, including staff use of cell phones, delayed call light responses, and staff speaking Spanish in resident areas. Documentation of resolutions was missing, and both the Activities Director and Administrator confirmed that these concerns were not addressed as required.
A resident reported a missing hearing aid shortly after admission, and both the resident and family requested a replacement and an audiology consult. Despite the grievance being documented, there was no evidence of follow-up, investigation, or communication about a replacement, and the administrator was unaware of the issue. The facility did not follow its grievance policy to resolve or address the loss.
A resident with multiple medical conditions had a Midline catheter placed in the upper arm, but there was no physician's order or documented care instructions for the device as required by facility policy. Review of records and staff interviews confirmed the absence of necessary orders and documentation for the Midline.
A resident with moderate cognitive impairment and multiple diagnoses experienced a decline in ADL performance after discharge from physical therapy. Despite increased dependence documented in care records, there was no evidence that the resident was re-evaluated by therapy or screened for rehab services, as required by facility policy.
A resident who was cognitively intact and required significant assistance lost a hearing aid shortly after admission and was left with an old, ineffective device. Despite a grievance filed by the resident's family and a physician's order for an audiology consult, there was no documentation of audiology services or replacement of the hearing aid. Staff interviews confirmed that the process to arrange these services was not completed.
A resident with diabetes and moderate cognitive impairment, who was fully dependent on staff for personal hygiene, did not receive necessary podiatry services despite having consented to them. The resident's toenails were observed to be long, jagged, and yellow, and there was no record of podiatry care being provided. Staff were unaware of the need for toenail care, resulting in a failure to follow facility policy for residents at risk for foot problems.
A resident with severe cognitive impairment and dysphagia experienced significant, rapid weight fluctuations while on tube feeding. Despite these changes, there was no documented follow-up or evaluation by the dietitian, physician, or nursing staff, and the care plan lacked specific nutrition interventions.
A resident with asthma, anxiety, and malnutrition was observed receiving oxygen therapy without a physician's order or a care plan addressing its use. Staff and the DON confirmed that both were required but missing from the medical record, in violation of facility policy.
A resident with PTSD and other complex diagnoses did not have a personalized care plan that addressed their specific traumatic experiences or included interventions to mitigate triggers, despite facility policy requiring trauma-informed care. The care plans referenced PTSD but lacked individualized details and strategies, and the Social Worker confirmed the absence of a personalized approach.
A resident with moderate cognitive impairment and a history of asthma was repeatedly observed with an albuterol inhaler left unsecured on the over-bed table, including when the resident was not present. Facility policy requires bedside medications to be locked, and there was no physician order, care plan, or assessment for self-administration. Both the nurse and the resident confirmed staff left the inhaler at the bedside.
A resident with heart failure and end stage renal disease on dialysis received fluids in excess of a physician-ordered 1,200 ml daily fluid restriction. Despite clear orders and facility policy, the resident was observed with unaccounted fluids at the bedside and received higher fluid volumes on several days. Staff interviews revealed a lack of monitoring and communication between nursing and dietary staff regarding the resident's total fluid intake.
A resident with complex medical needs fell and sustained a head injury due to inadequate supervision and communication in an LTC facility. The CNA assigned to the resident was not informed of the need for two-person assistance, leading to the resident rolling out of bed during care. The incident underscores a failure in communication between nursing staff and CNAs.
A facility failed to obtain written informed consents for psychotropic medications from a resident's health care proxy before administration. Despite the facility's policy requiring informed written consent, the resident received medications such as Depakote, Lacosamide, Seroquel, and Trazodone without documented consent. Interviews revealed staff were unaware of the policy, and the Director of Nursing confirmed the absence of necessary documentation.
A resident with dementia and arthritis experienced a new onset of limited range of motion in their hand, which was not addressed by the facility. Despite observations and reports from staff and family, the resident had not been screened or received therapy services since 2018. The facility lacked a policy for managing limited range of motion, and there was no documentation or referral to rehabilitation services until prompted by surveyors. An OT assessment confirmed impaired range of motion, highlighting a delay in appropriate care.
A resident with end-stage renal disease and a right chest catheter for dialysis access did not receive individualized care for their IJ catheter. The facility's records lacked specific plans and physician's orders for monitoring the catheter, and staff interviews revealed a lack of awareness and documentation regarding the catheter care. The care plan included interventions for an extremity fistula instead of the IJ catheter, and no recent education was provided for staff on managing such cases.
The facility failed to ensure nursing staff had the necessary competencies to care for residents requiring specialized treatments, such as dialysis. A resident with an IJ catheter for hemodialysis did not have a specific care plan, and staff lacked training to manage the catheter. Additionally, three out of four licensed nursing staff had no evidence of competency evaluations upon hire or annually.
The facility failed to secure and maintain medication carts properly, with instances of unlocked and unattended carts on two units, and a cart found with loose pills and a sticky substance. Staff interviews confirmed these practices were against facility policy.
The facility failed to serve meals at appropriate temperatures, as observed during a survey. Residents reported dissatisfaction with food quality, noting that hot foods were not served hot and cold foods were not served cold. The surveyor found that liquids were served at temperatures above the facility's policy, and food trucks were left open during delivery, allowing food to cool. Test trays confirmed that meals were not served at palatable temperatures.
The facility failed to maintain sanitary conditions in the kitchen, with multiple instances of improperly stored and unlabeled food items, and a staff member plating food without a beard net. Opened food items were found unlabeled and undated, and some were past their discard date, violating the facility's food safety protocols.
Two residents were found with devices that acted as restraints without proper assessment or documentation. One resident with dementia and ataxia was observed with a scoop mattress and side rails blocking bed exit, while another with severe cognitive impairment and hemiplegia had side rails and pillows acting as restraints. Both lacked care plans or doctor's orders for these restraints.
A resident with severe cognitive impairment and mobility issues was found with a bruise and skin tear of unknown origin. The facility's policy required immediate reporting of such incidents to the DON, but this was not done, preventing a full investigation. The oversight highlights a failure to implement the abuse prohibition policy.
A resident with severe cognitive impairment and mobility issues was found with a bruise and skin tear of unknown origin. The facility failed to report this injury to the state agency as required by their policy. The DON was not informed, and no investigation was conducted, leading to a deficiency in compliance with state regulations.
A resident with dementia and stroke-related conditions was found with a bruise and skin tear of unknown origin. The facility failed to conduct a thorough investigation as required by their policy, as the DON was not informed of the incident. This lack of communication and failure to follow procedures led to a deficiency.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including a high fall risk and pain. The facility's policy mandates the creation of a baseline care plan within 48 hours, covering essential healthcare information. Interviews with staff confirmed the lapse, as the necessary care plans for fall risk and pain were not developed, despite the resident's recent fall and other health conditions.
The facility failed to develop and implement care plans for two residents, one of whom required assistance with activities of daily living and was at risk of falls, and the other required an air mattress. The absence of care plans for these areas was confirmed by a review of the residents' records, which failed to include any such plans.
A resident with a known diagnosis of constipation and on narcotics for pain management went nine days without a documented bowel movement due to the facility's failure to implement the bowel management protocol. Despite the resident's requests for a suppository, staff did not follow the protocol or notify the physician in a timely manner. The resident's care plan lacked necessary interventions, and staff interviews confirmed the oversight.
A facility failed to ensure a clinical indication for the use of an indwelling urinary catheter for a resident admitted with it. The facility's policy requires specific medical reasons for catheter use, but the hospital discharge summary lacked documentation of such indications. Staff interviews revealed uncertainty about the catheter's necessity, with some suggesting the resident's declining condition as a reason. The nurse practitioner noted the absence of clinical indication in the resident's chart, highlighting a deficiency in policy adherence.
A resident with severe cognitive impairment and a gastrostomy tube was not connected to their enteral feeding as per physician's orders, which specified 20 hours of feeding per day. Observations showed the resident away from their room and not receiving the prescribed feeding. Facility records lacked documentation of this deviation, and staff interviews confirmed the expectation for continuous feeding until the specified time.
A facility failed to maintain a PICC line dressing for a resident as per physician orders. The resident, admitted with conditions requiring IV antibiotics, had a PICC line with a dressing dated over a week old, despite orders for weekly changes. Observations noted blood under the dressing, and no documentation of a dressing change was found in the resident's records. The DON confirmed the expectation for weekly dressing changes.
A facility failed to maintain an accurate account of a Fentanyl patch for a resident with quadriplegia and stroke. The nurse applied a new patch but did not report the missing old patch, violating the facility's policy. The DON was not informed, and no investigation was conducted, with the narcotic recording book lacking documentation of the missing patch.
A resident with rheumatoid arthritis and malnutrition was not provided with necessary built-up utensils during meals, despite facility policy and care plans requiring them. Observations showed the resident struggled to eat without these utensils, and interviews with staff confirmed the expectation for their provision.
A facility failed to accurately document the dressing change of a PICC line for a resident with osteomyelitis and cellulitis. The dressing was observed to be dated incorrectly, and there was no evidence in the progress notes that the dressing changes were completed as recorded in the Medication Administration Record. The DON expected that signed-off orders would be completed as documented.
The facility failed to follow proper infection control practices as CNAs were observed carrying dirty, un-bagged linens through hallways on the Pentucket Unit. The Unit Manager and DON confirmed that linens should be bagged for transport and gloves should not be worn in hallways. The facility also lacked a policy for linen transport.
Two residents who consented to receive pneumococcal vaccines did not receive them due to a failure in the facility's process. Despite signed consents, there were no physician orders or records of administration. Staff interviews revealed that the necessary notifications to the Infection Control Nurse and physician were not made, resulting in the oversight.
A resident with cognitive intactness but physical dependency was found with a gap between the mattress and footboard of their bed, posing a risk of entrapment. The gap resulted from the bed being extended due to the resident's height, but maintenance failed to fill the gap with a gap filler. Facility staff acknowledged the oversight, indicating a lapse in protocol.
A resident with Parkinson's disease and asthma experienced a non-functional call light system over a holiday weekend, leading to a deficiency. The resident and their roommate had to yell for help as their call lights were not working. Staff were aware but did not provide alternative means like handbells until after the weekend. The issue was only addressed after the holiday when the Maintenance Director was informed.
A Unit Secretary, lacking current training or certification, assisted a resident with dysphagia during a meal due to staff unavailability. The resident, with severe cognitive impairment, requires staff assistance for eating. The facility's Director of Nursing confirmed that only trained staff should assist with meals, and no policy was provided regarding meal assistance.
A resident with severe cognitive impairment and multiple diagnoses was not accurately documented as receiving hospice services on their MDS assessment. Despite physician orders and a care plan indicating hospice care, the MDS failed to reflect this status. The MDS Nurse and DON acknowledged the oversight during a review.
Failure to Track and Measure QAPI Program Performance
Penalty
Summary
The facility failed to maintain an effective system for tracking and measuring the performance of its Quality Assurance and Performance Improvement (QAPI) program. According to the facility's own QAPI policy, the program should be comprehensive, data-driven, and include processes for tracking and measuring performance, establishing goals and thresholds, and monitoring the effectiveness of corrective actions. However, a review of QAPI meeting minutes for March and April did not show any evidence of tracking QAPI performance or outcomes. The documentation lacked data collection, analysis, or any indication of how performance was being measured or evaluated against set goals. During an interview, the Administrator stated that performance was monitored through morning meetings and that the DON kept track of falls, but was unable to specify what the compliance or target goals were for the issues identified in the QAPI plan. The QAPI minutes included discussions on antipsychotic use, pharmacy issues, maintenance repairs, and falls, but did not document any measurable outcomes or tracking of progress toward resolution. This lack of documentation and measurable tracking constitutes a deficiency in the facility's QAPI program.
Incomplete Infection Surveillance Documentation and Lack of Trend Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by its own policy and national standards. Review of the infection control line listings for January, February, and March 2025 revealed that critical information was missing from the documentation. Specifically, the 'signs and symptoms' column was left blank for a significant number of infections each month, and the 'organism' column was incomplete for several urinary tract infections. This incomplete documentation hindered the facility's ability to accurately track and monitor infections among residents. During an interview, the Infection Preventionist (IP) confirmed that the facility uses McGeer's criteria to determine if a suspected infection qualifies for treatment, which requires documentation of specific signs and symptoms. The IP acknowledged that the facility does not document treatment outcomes or analyze trends to identify potential sources or patterns of infection spread, such as specific rooms or staff members. The IP also stated that all columns in the line listings should be completed to ensure accurate infection tracking, and that outcomes and trends should be identified and addressed, but this was not being done.
Failure to Implement Antibiotic Stewardship Program and Timely Review of Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program as outlined in its policy, which requires the collection and documentation of antibiotic usage and outcome data using an approved surveillance tracking form. The policy also states that the Infection Preventionist (IP) is responsible for reviewing antibiotic utilization and identifying instances of inappropriate antibiotic use, as well as reviewing and documenting the outcomes of antibiotic therapy. However, a review of the facility's line listings for January, February, and March 2025 showed that a total of 77 antibiotics were prescribed during this period, with no documented follow-up or review with a physician or nurse practitioner after the initiation of any of these antibiotics. During an interview, the IP confirmed that there is no review for appropriateness or efficacy of antibiotics until she has time to review the monthly infection control line listings, despite acknowledging that antibiotics should be reviewed within 48-72 hours of initiation.
Failure to Develop and Implement Required Care Plans and Interventions
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents as required. For one resident with a history of major depressive disorder, opioid abuse, PTSD, and alcoholic cirrhosis, the care plan did not address substance use disorders. The resident's social service history and evaluation documented alcohol and opioid abuse, but the care plan lacked interventions, triggers, or support plans for these issues. The social worker confirmed that care plans for alcohol and opioid abuse should have been developed for this resident. For another resident with diagnoses including Type 2 Diabetes Mellitus, myxedema coma, bipolar disorder, and depression, the facility failed to implement physician-ordered geri-sleeves to the resident's arms and legs. Multiple observations over several days showed the resident was not wearing the required geri-sleeves, and there was no documentation of refusal in the nursing notes. Interviews with nursing staff revealed a lack of awareness of the order, and the resident reported not having worn the sleeves for about a month. The administrator stated that the expectation was for the sleeves to be worn as ordered and refusals to be documented.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to respond to and resolve concerns raised by residents during monthly resident council meetings over a three-month period. Resident council minutes from February, March, and April documented repeated grievances regarding staff, including aides and nurses using cell phones and ear buds while on duty, delayed response times to call lights, and staff speaking Spanish in resident rooms and hallways. Despite these concerns being consistently reported in the council meetings, there was no supporting documentation indicating that the facility addressed or resolved these issues. Interviews with the Activities Director and the Administrator confirmed that concerns raised in resident council meetings should be reported to the Administrator and addressed in a timely manner, with documentation of resolutions filed with the council minutes. However, the Administrator was unable to locate any records of resolutions for the concerns raised from February to April, and residents reported that their issues were not being addressed. The lack of documented follow-up and resolution constitutes a failure to honor residents' rights to have their grievances addressed through the resident council process.
Failure to Promptly Resolve Grievance Regarding Lost Hearing Aid
Penalty
Summary
The facility failed to provide a prompt resolution or adequate follow-up on a grievance regarding a lost hearing aid for one resident. The resident reported a missing hearing aid shortly after admission, and the grievance was documented in the facility's grievance book. Notes indicated that the resident and family confirmed the missing left hearing aid and requested to see an audiologist for a replacement. However, there was no evidence in the medical record that the lost hearing aid was documented or that the resident was seen by an audiologist. The resident's daughter also reported that after filing the grievance, she did not receive any follow-up or information about obtaining a replacement, aside from being asked to fill out another consent form. During interviews, the administrator was unaware of the missing hearing aid and stated that an investigation and efforts to obtain a replacement should have occurred. The facility's policy requires prompt efforts to resolve grievances, including keeping the resident informed of progress and submitting investigative results for misappropriation of property. In this case, the facility did not follow its policy, as there was no documented investigation, resolution, or communication with the resident or family regarding the lost hearing aid.
Failure to Obtain Physician's Order for Midline Catheter Placement and Care
Penalty
Summary
The facility failed to ensure that care provided to Resident #154 met professional standards of quality by not obtaining a physician's order for the placement and care of a Midline catheter. Resident #154, who was admitted with diagnoses including urinary tract infection, recent fall, and high blood pressure, had a Midline placed in the right upper arm as documented on 4/16/25. However, a review of the physician's orders, treatment administration record, and care plan for April 2025 did not show any documentation of a physician's order for the Midline placement or its care. Interviews with the Unit Manager and the Director of Nursing confirmed the absence of the required physician's order and care instructions for the Midline, which is contrary to the facility's policy requiring a prescriber's order for vascular access devices.
Failure to Re-Evaluate Resident for Rehab Services After Decline in ADLs
Penalty
Summary
The facility failed to obtain rehabilitation services for a resident who experienced a decline in activities of daily living (ADLs). According to facility policy, residents are to receive care and services to maintain or improve their ability to perform ADLs, and those identified as needing functional assessment should be evaluated for rehabilitation services. The resident in question, admitted with diagnoses including anxiety, dementia, and unsteadiness, had moderate cognitive impairment and required substantial to maximal assistance with ADLs. After being discharged from physical therapy, the resident's care documentation showed a further decline in ADL performance, with increased dependence noted in toileting, bathing, transfers, and mobility. Despite this documented decline, there was no evidence in the medical record or therapy notes that the resident was re-evaluated by therapy or screened for potential rehabilitation services following the change in condition. The Director of Rehab confirmed that no screen or evaluation was found after the resident's decline, although facility policy requires notification and assessment by the rehab department in such cases. This lack of follow-up and failure to initiate a therapy evaluation after a significant decline in ADLs constituted the deficiency identified by surveyors.
Failure to Replace Lost Hearing Aid and Arrange Audiology Services
Penalty
Summary
The facility failed to provide adequate hearing services for one resident who was admitted with multiple diagnoses, including a left femur fracture, anemia, and anxiety. The resident was cognitively intact, as indicated by a BIMS score of 13 out of 15, and required substantial to maximal assistance with daily tasks. Shortly after admission, the resident's hearing aid was lost, and the resident was observed wearing an old, non-functional hearing aid. The resident reported the missing hearing aid during a Resident Council Meeting, and the issue was confirmed by the resident's daughter, who stated that a grievance had been filed but no follow-up or replacement was provided. A review of the resident's medical record showed a physician's order for an audiology consult as needed, but there was no documentation that the resident had been seen by an audiologist. Interviews with facility staff indicated that the social worker, DON, and unit manager were responsible for arranging audiology services and obtaining a replacement hearing aid, but these actions were not completed. The administrator confirmed that the expectation was for the resident to be seen by an audiologist and provided with a replacement hearing aid, which had not occurred.
Failure to Provide Podiatry Services for Dependent Diabetic Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and moderate cognitive impairment, did not receive appropriate foot care services. The resident was totally dependent on staff for personal hygiene and had signed a consent form for podiatry services. Despite this, there was no documentation in the medical record indicating that the resident had ever been seen by a podiatrist. During an observation, the resident's toenails were found to be long, jagged, and yellow, and the resident reported not having their toenails cut or being seen by a podiatrist. Facility policy required that residents with conditions such as diabetes receive toenail care from a physician or practitioner. Staff interviews revealed that the process for identifying residents in need of podiatry services involved notifying the unit secretary when long toenails were observed, so the resident could be added to the next podiatry visit. However, the nurse interviewed was unaware that this resident required toenail care, indicating a breakdown in the facility's process for ensuring necessary podiatry services were provided.
Failure to Follow Up on Significant Weight Changes
Penalty
Summary
A deficiency occurred when the facility failed to follow up on significant weight changes for a resident with dysphagia and severe cognitive impairment. The resident, who required tube feeding due to difficulty swallowing, experienced notable fluctuations in weight over a short period, including both significant losses and gains. The care plan identified risks related to altered nutrition and hydration status but did not include specific interventions for nutrition. Weight records showed multiple instances of weight changes exceeding 5 pounds, which, according to the facility dietitian, should have triggered further evaluation. Despite these significant weight fluctuations, there was no documentation in the medical record indicating that the dietitian, physician, or nursing staff followed up on the changes. The dietitian stated she was not notified of the weight changes and would have expected to be informed to assess the resident. The lack of follow-up and absence of documentation regarding the significant weight changes constituted the deficiency identified by surveyors.
Failure to Obtain Physician's Order and Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that a physician's order was present for the administration of oxygen and by not developing a care plan for its use. Observations on two consecutive days showed the resident receiving oxygen via nasal cannula at 1 L/min, but a review of the medical record revealed no physician's order authorizing this treatment. Additionally, the resident's care plan did not address the use of oxygen, despite facility policy requiring verification of a physician's order and care plan review prior to administration. The resident involved had diagnoses including asthma, anxiety, and malnutrition, and was assessed as having moderately impaired cognition, requiring partial to maximal assistance with activities of daily living. Interviews with nursing staff and the Director of Nursing confirmed that both a physician's order and a care plan should have been in place for the use of oxygen, but neither was found in the resident's records.
Failure to Develop Personalized PTSD Care Plan
Penalty
Summary
The facility failed to develop a personalized care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), major depressive disorder, opioid abuse, and alcoholic cirrhosis. Despite the facility's policy requiring trauma-informed care that accounts for residents' experiences and preferences, the care plans reviewed did not document the resident's specific traumatic experiences or include interventions to mitigate identified triggers. The resident's trauma history, as documented in a brief trauma questionnaire, included personal experiences of serious accidents, exposure to toxic substances, physical assault, and other very stressful events. Care plans initiated for the resident referenced PTSD and related risks but did not detail the traumatic events or provide individualized interventions to address or reduce exposure to triggers that could cause re-traumatization. During an interview, the Social Worker confirmed that the PTSD care plan was not personalized and lacked documentation of the resident's traumatic experiences and specific strategies to mitigate triggers, as required by facility policy.
Failure to Secure Medications at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with state and federal requirements, specifically by allowing a medication to be left at the bedside of a resident. Facility policy requires that medications stored at the bedside be kept locked in a secure container, and that nurses are responsible for maintaining medication storage in a clean, safe, and sanitary manner. However, multiple observations revealed that an albuterol inhaler was left on the over-bed table of a resident with moderate cognitive impairment and a history of asthma, anxiety, and malnutrition. The inhaler was observed unattended on several occasions, including when the resident was not present in the room and the door was open. Review of the resident's records showed no physician's order for self-administration of medications, no care plan for self-administration, and no assessment indicating the resident was capable or desired to self-administer medications. In fact, documentation indicated the resident did not want to self-administer medications. During interviews, both the nurse and the resident confirmed that the inhaler had been left at the bedside by staff, contrary to facility policy and regulatory requirements.
Failure to Follow Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a fluid restriction for one resident with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis. The resident was prescribed a 1,200 ml fluid restriction per 24 hours, with specific allocations for nursing and dietary staff. Despite this, record review showed that the resident received fluids in excess of the prescribed limit on multiple days, with documented intakes ranging from 1,357 ml to 2,537 ml. Observations also revealed that the resident had access to additional fluids at the bedside, including a cup with liquid and multiple bottles of water, which were not accounted for in the fluid restriction plan. Interviews with facility staff indicated a lack of communication and monitoring regarding the resident's fluid intake. The dietitian was unaware that the resident was receiving fluids outside of the restriction and expected nursing to monitor and address any deviations. The DON confirmed that the expectation was for the fluid restriction to be followed as ordered. Facility policy required that fluid restrictions be adhered to according to physician orders, with proper documentation and communication if the resident refused the restriction, but there was no evidence that these procedures were followed in this case.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who required the help of two staff members for bed mobility and care. The resident, who had been readmitted to the facility after a hospital stay for pneumonia, was not properly communicated about to the Certified Nurse Aide (CNA) assigned to their care. The CNA, unaware of the resident's need for two-person assistance, attempted to provide care alone, resulting in the resident rolling out of bed and sustaining a head laceration that required medical attention. The resident had a complex medical history, including a cerebral vascular accident with right hemiparesis, chronic respiratory failure, and other conditions that necessitated careful handling and supervision. Upon readmission, the resident was noted to be bed-bound and required a Hoyer lift for transfers. Despite these needs, the evening shift nurse did not communicate the resident's care requirements to the CNA before the incident occurred. The CNA, unfamiliar with the resident and lacking detailed information on the assignment sheet, proceeded to provide care without assistance. During this process, the resident let go of the side-rail and fell, hitting their head on the nightstand. The incident highlights a breakdown in communication and supervision, as the CNA was not informed of the resident's specific care needs, leading to the accident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consents for psychotropic medications from the health care proxy (HCP) of a resident with an invoked HCP, prior to administering the medications. The facility's policy requires that psychotropic medications not be administered without informed written consent, which must be documented and kept in the resident's medical record. However, the facility did not adhere to this policy for the resident in question. The resident, who was admitted with multiple diagnoses including Lewy Body Dementia, was prescribed several psychotropic medications such as Depakote, Lacosamide, Seroquel, and Trazodone. Despite the facility's policy, there was no documentation of informed consent for these medications in the resident's medical record. Interviews with nursing staff revealed a lack of awareness and adherence to the facility's informed consent policy, as they administered these medications without obtaining the necessary consents. The Director of Nursing (DON) confirmed the absence of written and signed informed consents for the resident's psychotropic medications. The DON stated that it is the expectation for nurses to obtain informed consent and discuss the medications with the resident or their legal representative before administration. However, the facility was unable to locate any documentation to support that informed consents were obtained, highlighting a significant oversight in following established procedures.
Failure to Address Limited Range of Motion in Resident
Penalty
Summary
The facility failed to identify and address a new onset of limited range of motion in a resident's hand, which was observed by surveyors. The resident, who was admitted in 2018 with diagnoses including dementia and arthritis, had not been screened or received therapy services since 2018. Despite observations and reports from staff and family members indicating that the resident had been holding their hands in a fisted position for several months, there was no documentation in the clinical record of any limited range of motion or contracture management. During the survey, it was noted that the facility did not have a policy regarding limited range of motion or contracture management. Interviews with CNAs and the Unit Manager revealed that the resident's condition had been ongoing, yet no referral to rehabilitation services had been made until prompted by the surveyor. The Rehab Director confirmed that screenings were based on nursing requests, and the resident's condition had not been previously addressed. The Occupational Therapist's assessment confirmed impaired range of motion in the resident's left hand, with pain during passive range of motion exercises. Despite the resident's condition being known to staff, including the Unit Manager and CNAs, there was a lack of communication and documentation regarding the resident's limited range of motion, leading to a delay in appropriate intervention and care.
Deficiency in Hemodialysis Catheter Care
Penalty
Summary
The facility failed to ensure professional standards of care for a resident requiring hemodialysis, specifically in the care and treatment of an internal jugular (IJ) catheter. The resident, who was admitted with end-stage renal disease and required dialysis, had a right chest catheter for dialysis access. Observations and interviews revealed that the catheter was wrapped in gauze, and the resident indicated that the dialysis center staff managed the catheter care. However, the facility's records, including the care plan and nursing progress notes, did not reflect a specific and individualized plan for the IJ catheter, and there were no physician's orders for its monitoring. Interviews with nursing staff and the Director of Nursing highlighted a lack of awareness and proper documentation regarding the resident's IJ catheter. The staff admitted that there were no orders for monitoring the catheter, and the care plan included interventions for an extremity fistula rather than the IJ catheter. The Unit Manager acknowledged the need for monitoring the catheter for bleeding, drainage, and dressing integrity, but noted that no recent education had been provided for residents requiring dialysis or IJ catheters. The Director of Nursing emphasized the importance of having physician's orders for monitoring the catheter access site.
Inadequate Competency and Training for Dialysis Care
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the appropriate competencies and skills to care for residents requiring specialized treatments, such as dialysis. Specifically, the facility did not provide adequate training or competency evaluations for the care of a resident with an internal jugular (IJ) catheter for hemodialysis. The resident, who was admitted with end-stage renal disease and required dialysis, had a catheter in the right chest, which was not properly addressed in the care plan. The care plan included interventions for an extremity fistula, which was not applicable to the resident's IJ catheter, and there were no specific physician's orders for the catheter's care. Observations and interviews revealed that the nursing staff lacked the necessary knowledge and training to manage the resident's IJ catheter. A nurse incorrectly stated that she would check the catheter for patency, bruit, and thrill, which are not applicable to an IJ catheter. The charge nurse and unit manager admitted to a lack of familiarity with the requirements for IJ catheter care and confirmed that no recent education had been provided for residents requiring dialysis or IJ catheters. The Director of Nursing acknowledged the need for caution with IJ catheters but did not ensure that staff were adequately trained. Additionally, a review of employee records showed that three out of four licensed nursing staff had no evidence of competency evaluations upon hire or annually. The Staff Development Coordinator, who had been in the role for a few months, was unable to locate documentation of competency evaluations for these staff members. Only one staff member had received competency training, which did not include dialysis training, further highlighting the facility's failure to ensure staff were equipped to care for residents with specialized needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medication carts were properly secured and maintained according to accepted professional standards. On two of the three units observed, medication carts were left unlocked and unattended, making them accessible to visitors and residents. Specifically, on the Pentucket Unit, a nurse left her medication cart unlocked multiple times while retrieving supplies, leaving medications exposed on top of the cart. Similarly, on another unit, a medication cart was found unlocked and unattended outside a resident's room, which was later noticed and locked by a charge nurse. Additionally, the facility did not maintain medication carts in a clean and orderly manner. During an inspection, one of the medication carts was found with approximately 11 loose pills in one of its drawers and a sticky pink substance in another drawer. Interviews with nursing staff and the Director of Nurses confirmed that medication carts should be locked when unattended and kept clean, free from loose pills and spills. These observations indicate a failure to adhere to the facility's policy on medication storage, which requires medications to be stored safely, securely, and properly.
Deficiency in Meal Temperature and Quality
Penalty
Summary
The facility failed to ensure that meals provided to residents were prepared and served at palatable and appetizing temperatures, as observed during a survey. Residents expressed dissatisfaction with the food quality, describing it as "yuck" and "institutional," and noted that hot foods were not served hot and cold foods were not served cold. These concerns were raised during a Resident Group Meeting, where all 17 participants reported issues with meal temperatures across all three daily meals. Despite raising these concerns in previous meetings, residents were informed that the facility was working on the issue. During the survey, the surveyor observed that the temperatures of liquids such as milk, juice, and soda ranged between 50 F and 70 F, which is above the facility's policy of keeping cold foods no greater than 41 F. The Food Service Director acknowledged that liquids were pre-poured and placed on trays before food plating, which could take over an hour, leading to elevated temperatures. Additionally, the surveyor noted that food trucks were left open during meal delivery, allowing food to cool. Test trays revealed that waffles were served at temperatures below the required 140 F, and beverages like milk, tea, and coffee were not at appropriate temperatures, further confirming the residents' complaints about meal temperature and quality.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions in the main kitchen, as observed during a survey. Several instances of improper food storage were noted, including nine cases of food placed directly on the floor of the food storage room. Numerous opened food items, such as cinnamon buns, milk, juices, applesauce, fruit, pasta, ham, and drinks, were found unlabeled and undated, which is against the facility's policy. Additionally, some items were past their discard date, such as a tray of Jello and fruit cups dated 5/21/24 and a container of ham salad dated 5/19/24. A jar of ketchup was also found with an opened date of 1/27/24, indicating it was kept beyond the recommended time frame. Furthermore, during the lunch service, a staff member with a beard was observed plating food without wearing a protective cover for his facial hair, which is a violation of the facility's hygiene standards. The Food Service Director confirmed that all open food should be labeled, dated, and discarded three days after opening, and that staff with facial hair should wear nets to prevent contamination. These observations highlight a lack of adherence to proper food storage and preparation protocols, potentially compromising food safety and hygiene in the facility.
Failure to Assess and Document Use of Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, as required by their policy. Resident #14, who has dementia with anxiety and ataxia, was observed with a scoop mattress and side rails that blocked the indentations meant for bed exit, effectively acting as a restraint. Despite the resident's moderate cognitive impairment and dependency for most activities of daily living, there was no care plan, doctor's order, or assessment for the use of these restraints. The resident had previously fallen while attempting to get out of bed without assistance, indicating a lack of proper assessment and planning for their safety and mobility needs. Similarly, Resident #97, with severe cognitive impairment and right-sided hemiplegia and hemiparesis, was observed with side rails and pillows wedged against them, which could act as a restraint. The resident was unable to remove the pillows independently, and there was no documentation of a care plan, doctor's order, or assessment for the use of these restraints. The CNA acknowledged that the pillows could act as a restraint, and the resident had attempted to get out of bed without assistance. The facility's failure to assess and document the use of these devices as potential restraints contributed to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident who was admitted with diagnoses including dementia and stroke-related conditions. The resident, who required substantial assistance from staff for mobility and had severe cognitive impairment, was found with a bruise and skin tear of unknown origin on the left upper arm. The incident was documented in a nurse's note and an event report, but the Director of Nursing (DON) was not informed of the injury, which was a requirement according to the facility's policy. The facility's policy, dated October 2022, mandates that any alleged violations involving abuse, including injuries of unknown source, should be immediately reported to the Administrator or the DON. However, in this case, the nursing staff did not report the incident to the DON, who stated that had she been informed, a full investigation would have been conducted. This oversight resulted in a failure to follow the established procedure for handling potential abuse cases, as outlined in the facility's policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of potential abuse or neglect to the state agency as required for a resident. The facility's policy on abuse, neglect, mistreatment, misappropriation of resident property, and exploitation, dated October 2022, mandates that any alleged violations involving abuse, including injuries of unknown source, should be immediately reported to the Administrator or Director of Nursing. An investigation should be initiated, and an initial report should be submitted to the Health Care Facility Reporting System. However, in this case, the facility did not adhere to these procedures. The incident involved a resident admitted in June 2023 with diagnoses including dementia and stroke-related paralysis and weakness. The resident was unable to complete a mental status exam due to severe cognitive impairment and required substantial assistance for mobility. On September 9, 2023, the resident was found with a bruise and skin tear of unknown origin on the left upper arm. Despite the facility's policy, this injury was not reported to the state agency. The Director of Nursing was not informed of the incident, and consequently, a full investigation was not conducted. The failure to report the injury as required constitutes a deficiency in the facility's compliance with state regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia and stroke-related paralysis and weakness, was found with a bruise and skin tear on the left upper arm. The incident was documented in the facility's records, but there was no evidence of a thorough investigation as required by the facility's policy on abuse and injuries of unknown origin. The Director of Nursing (DON) was not informed of the injury, and as a result, no investigation was initiated. The facility's policy mandates that any injury of unknown origin should be immediately reported to the Administrator or DON, and a full investigation should be conducted, including staff interviews and documentation. The lack of communication and failure to follow the established procedure resulted in the deficiency noted by the surveyors.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for a resident. The facility's policy requires that a baseline care plan be created within 48 hours, including essential healthcare information such as initial goals, physician's orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. However, upon review, it was found that the resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a recent fall, did not have a baseline care plan addressing their high fall risk or pain. Interviews with facility staff, including a Unit Manager and the Director of Nursing, confirmed that the responsibility for creating baseline care plans lies with the nurse conducting the admission assessment. The Unit Manager acknowledged that baseline care plans should cover fall risk, pain, and other specific care needs related to the resident's diagnoses and behaviors. Despite this, the necessary care plans were not developed for the resident, indicating a lapse in adherence to the facility's care planning policy.
Deficiencies in Care Planning for Residents
Penalty
Summary
The report identifies a deficiency in the facility's failure to develop and implement care plans for a resident, identified as Resident #108. Despite the recognition of the need for a care plan due to the resident's condition, the facility failed to create a care plan for the resident's activities of daily living, as well as for the use of psychotropic medications. This oversight was identified during a review of the facility's records, which revealed that the resident had been prescribed medications that required monitoring and that the resident was at risk of falls. The absence of a care plan for these areas was confirmed by a review of the resident's records, which failed to include any such plans. In addition, the report highlights a deficiency related to another resident, identified as Resident #64, where the facility failed to implement a care plan for the use of an air mattress. Despite the recognition of the need for a care plan, the facility failed to ensure that the air mattress was set according to the resident's weight, as required by the physician's orders. This oversight was identified during a review of the facility's records, which revealed that the air mattress was not being used according to the physician's orders. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The report also highlights a deficiency related to the facility's failure to implement a care plan for the use of an air mattress. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to prevent constipation and implement the bowel management protocol for a resident with a known diagnosis of constipation, who was also receiving narcotics for pain management, which increased the risk for constipation. The facility's policy required timely assessments and interventions for bowel management, but these were not followed for the resident. The resident had no documented bowel movements from May 19 to May 27, despite having physician's orders for laxatives and enemas as needed. The resident expressed concerns about constipation and requested a suppository, but was told by nurses that there was no order and they had to wait for the doctor. The resident's care plan did not include a bowel management protocol or individualized interventions for constipation. The medical record showed a lack of documentation and monitoring of bowel movements, and the nursing staff failed to notify the physician or implement the bowel management protocol in a timely manner. Interviews with staff revealed that the bowel management protocol was not put in place for the resident, and the nursing staff did not adequately monitor the resident's bowel movements. The Unit Manager and Director of Nursing acknowledged the oversight and confirmed that the protocol should have been implemented, given the resident's risk factors for constipation due to pain medication use.
Lack of Clinical Indication for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that the use of an indwelling urinary catheter for a resident had a clinical indication, as required by their policy. The resident was admitted with an indwelling catheter, but the facility did not verify the clinical necessity for its continued use. The facility's policy states that indwelling catheters should only be used for specific medical reasons, such as urinary retention that cannot be treated otherwise, contamination of pressure ulcers, terminal illness, or acute illness requiring fluid balance monitoring. However, the documentation from the hospital did not provide a clear indication for the catheter's use, nor was there evidence of a bladder scan to confirm urinary retention. The resident in question had a history of several medical conditions, including hypertension, chronic kidney disease, and deep vein thrombosis, but was not documented as having unhealed pressure ulcers or a life expectancy of less than six months. The care plan noted the catheter was related to urinary retention reported by the hospital, yet the hospital discharge summary lacked documentation of a bladder scan or any clinical indication for the catheter. Interviews with facility staff revealed uncertainty about the necessity of the catheter, with some staff suggesting the resident's declining condition and comfort care status as possible reasons for its use. Despite the resident being admitted with the catheter, the facility did not conduct a voiding trial or follow up on the hospital's discharge summary to confirm the need for the catheter. The nurse practitioner acknowledged the lack of clinical indication in the resident's chart and expressed hesitation to remove the catheter due to the resident's transition to comfort care. This oversight in verifying the clinical necessity for the indwelling catheter represents a deficiency in the facility's adherence to its own policy and regulatory standards.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident with severe cognitive impairment and a gastrostomy tube. The resident, who was admitted with diagnoses including dysphagia following cerebral infarction and dementia, was observed on multiple occasions not being connected to their enteral feeding as per the physician's order. The physician's order specified that the resident should receive Jevity 1.2 Cal at 85 ml/hr for 20 hours per day, from 6:00 P.M. to 2:00 P.M. However, on the day of observation, the resident was seen in a wheelchair away from their room and not connected to the feeding tube during the prescribed feeding hours. The facility's progress notes did not document any deviation from the physician's orders or any notification to the physician regarding the early disconnection of the enteral feeding. Interviews with the Unit Manager and the Director of Nurses confirmed that the expectation was for the resident to remain connected to the enteral feeding until the specified time of 2:00 P.M., regardless of their location within the facility. This oversight indicates a failure to implement the physician's orders correctly, leading to a deficiency in the care provided to the resident.
Failure to Maintain PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) line for a resident, consistent with professional standards of practice. The resident, who was admitted with diagnoses including osteomyelitis, pathological fracture, and cellulitis, had a PICC line for IV antibiotics. The facility's policy required dressing changes according to physician orders or when the dressing was compromised. However, observations revealed that the dressing on the resident's PICC line, dated 5/16/24, had not been changed as ordered, despite visible blood under the dressing. The physician's orders specified a weekly dressing change, and the resident's care plan also indicated the need for dressing changes as ordered. A review of the resident's progress notes showed no documentation of a dressing change since admission. During an interview, the Director of Nurses acknowledged the expectation for weekly dressing changes in accordance with physician orders or as needed if the dressing was soiled and peeling.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to maintain an accurate account of a controlled medication, specifically a Fentanyl patch, for a resident with quadriplegia and a history of stroke who experienced frequent pain. The resident was prescribed a Fentanyl patch to be applied every three days. On the date in question, the nurse applied the Fentanyl patch as ordered, but the previously applied patch was found to be missing. The nurse did not notify the administration of the missing patch, as required by the facility's policy. The facility's policy mandates that any discrepancy or suspected loss of a controlled substance should be immediately reported to the Administrator, Director of Nursing (DON), and Consultant Pharmacist, followed by an investigation. However, the DON was not informed of the missing Fentanyl patch, and no investigation was conducted. Additionally, the narcotic recording book did not document the removal or destruction of the old patch, nor did it note that the patch was missing, indicating a failure to adhere to the facility's procedures for handling controlled substances.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them, as observed by surveyors. Resident #101, who was admitted with conditions including rheumatoid arthritis and moderate protein calorie malnutrition, was not provided with built-up utensils with foam during meal services. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the resident struggled to eat without the adaptive utensils, dropping the fork multiple times and expressing difficulty in holding standard utensils due to hand issues. The facility's policy on adaptive eating equipment, dated 2/12/24, mandates that such devices be sanitized and placed on the resident's tray as needed. However, observations on multiple occasions revealed that Resident #101's meal trays lacked the required built-up utensils, contrary to the active nutrition care plan and nutrition notes specifying their necessity. Interviews with the Unit Manager and the Director of Nurses confirmed that the expectation was for the built-up utensils to be provided with each meal, highlighting a lapse in ensuring the resident's care plan was followed.
Inaccurate Documentation of PICC Dressing Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a peripherally inserted central catheter (PICC) dressing change. The resident, who was admitted with osteomyelitis, a pathological fracture, and cellulitis, was observed with a PICC line in the right arm. The dressing on the PICC line was dated 5/16/24, and there was a red substance consistent with blood under the dressing. Despite physician orders and the resident's care plan indicating that the PICC dressing should be changed weekly, the Medication Administration Record inaccurately documented that the dressing changes were completed on 5/20/24 and 5/27/24. The surveyor's observations and the review of the resident's progress notes revealed that there was no indication that the PICC line dressing change was actually completed on the dates recorded. During an interview, the Director of Nurses stated that she would expect the orders signed off on the Medication Administration Record to have been completed as ordered. This discrepancy between the documentation and the actual care provided led to the identification of the deficiency in maintaining accurate medical records in accordance with professional standards.
Improper Linen Transport Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the transportation of dirty linens on the Pentucket Unit. Observations by the surveyor revealed that multiple Certified Nursing Assistants (CNAs) were seen exiting resident rooms with gloved hands, carrying dirty, un-bagged linens through the hallway to the dirty laundry room. This occurred on several occasions within a short time frame, involving at least five different CNAs. During interviews, the Unit Manager and the Director of Nurses confirmed that the staff should not be transporting dirty linens un-bagged or wearing gloves in the hallway. Additionally, the facility lacked a policy for transporting linens, as confirmed by the Administrator.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer pneumococcal vaccinations to two residents who had consented to receive them. Resident #93, admitted in August 2023 with a diagnosis of dementia, signed a consent form for the pneumococcal vaccine on 8/17/23. However, a review of the medical records showed no evidence that the vaccine was administered. Similarly, Resident #101, admitted in March 2024 with conditions including rheumatoid arthritis and moderate protein-calorie malnutrition, also consented to the pneumococcal vaccine on an undated form, but there was no record of the vaccine being given. Interviews with facility staff revealed a breakdown in the process for administering vaccines. The Infection Control Nurse confirmed that the facility's procedure involves offering vaccines upon admission and obtaining physician orders for administration. However, she found no physician orders for the pneumococcal vaccine for either resident and confirmed that neither had a recorded history of receiving the vaccine. Nurse #3 and Unit Manager #3 indicated that the process involves notifying the Infection Control Nurse and the physician when a resident consents to a vaccine, but this step was not completed, leading to the oversight.
Failure to Ensure Bed Safety for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident's bed, leading to a potential risk of entrapment. Resident #79, who is cognitively intact but dependent on assistance for activities of daily living and rolling side to side in bed, was observed with a gap between the mattress and the footboard of the bed. This gap was approximately four inches wide, as confirmed by the Maintenance Director. The resident had previously mentioned discomfort due to their feet hitting the footboard, and it was noted that the bed had been extended by maintenance staff due to the resident's height. Interviews with facility staff, including the Unit Manager and the Director of Nurses, revealed that there should not have been a gap between the mattress and the footboard, as it poses a risk of entrapment. The Unit Manager indicated that maintenance or central supply should have been notified to fill the gap with a gap filler, which was not done. The Director of Nurses also confirmed that there should be no gaps to prevent entrapment, highlighting a lapse in the facility's protocol for ensuring bed safety.
Non-Functional Call Light System Over Holiday Weekend
Penalty
Summary
The facility failed to ensure that the call light system was functional for a resident, leading to a deficiency. The resident, who was cognitively intact and had diagnoses including Parkinson's disease and asthma, reported that their call light had not been working over a holiday weekend. The resident had to resort to yelling for help, as their roommate's call light was also non-functional. Despite being aware of the issue, staff informed the resident that repairs would not be possible until after the holiday weekend. The surveyor confirmed that the call lights were not operational during an observation. The Unit Manager and Maintenance Director were only informed of the issue after the weekend, at which point the call lights were fixed. The facility had handbells available as an alternative means for residents to call for help, but these were not provided to the resident or their roommate during the outage. A family member of the resident had brought a small bell for temporary use, but it was not effective in alerting staff due to the room's distance from the nurse's station. The Director of Nursing acknowledged that staff should have provided handbells and notified maintenance sooner.
Untrained Staff Assisted Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that staff assisting residents with meals completed the required training. On a specific date, a Unit Secretary, who was not trained or certified, assisted a resident with a diagnosis of dysphagia during breakfast. This resident, admitted in 2018, has severe cognitive impairment and is dependent on staff for eating, as indicated by the Minimum Data Set Assessment. The resident's speech therapy discharge summary highlighted the need for staff training in feeding assistance and swallow-safe strategies. During the incident, the Unit Secretary, who had previously worked as a CNA but had not maintained her license or training, assisted the resident due to a lack of available staff in the dining room. The Unit Manager intervened and requested a CNA to assist the resident instead. Interviews with the Director of Nursing and Staff Development Coordinator confirmed that only certified or trained staff should assist with meals, and the Unit Secretary's actions were not in line with facility expectations. The facility did not provide a policy regarding staff assistance with meals.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. A resident, who was admitted with chronic kidney disease, malignant-related fatigue, and severe protein-calorie malnutrition, was not accurately documented as receiving hospice services on their MDS assessment. Despite physician orders indicating the resident's evaluation and admission to hospice services, and a care plan revision confirming hospice care, the MDS assessment did not reflect this status. The MDS Nurse acknowledged the oversight during a review with a surveyor, noting that hospice services should have been indicated in section O of the MDS. The Director of Nurses also confirmed the expectation for accurate coding of the MDS to reflect the resident's hospice status.
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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