Hellenic Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Massachusetts.
- Location
- 601 Sherman Street, Canton, Massachusetts 02021
- CMS Provider Number
- 225418
- Inspections on file
- 19
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Hellenic Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to maintain proper communication with a dialysis center for a resident with end-stage renal disease, as required by their agreement. Despite the resident's need for thrice-weekly dialysis, the facility did not complete necessary communication forms for nearly a year. Interviews with staff confirmed the lack of documentation, and the dialysis nurse noted that forms were only completed if unusual events occurred.
The facility failed to properly label and store food in accordance with professional standards, risking foodborne illness. Surveyors found unlabeled food items in the main kitchen and nourishment kitchenettes, and a dirty refrigerator on the third floor. The FSM acknowledged the failure to follow labeling policies and the need for proper sanitation.
A facility failed to provide complete informed consent for a resident receiving Bupropion, a psychotropic medication. The consent form did not specify the administered dose, benefits, or correct dose range, which should have included the total daily dose of 225 mg. The resident, with dementia and bipolar disorder, had a Health Care Proxy activated, and the discrepancies were confirmed by staff during a review.
A resident with a Stage 4 pressure ulcer did not receive the recommended antibiotic treatment because the facility failed to notify the Physician/Practitioner of the Wound Consultant's recommendation. The resident's records showed no administration of the antibiotic, and interviews revealed that the recommendation was not communicated to the necessary medical staff.
The facility failed to maintain a homelike environment in the C Unit Lounge, which was used to store resident equipment like wheelchairs and mattresses. Observations and interviews revealed that the lounge, intended for resident activities, was cluttered with unused equipment, making it unwelcoming. Staff and residents confirmed the lounge's use as a storage area to keep resident rooms less cluttered.
The facility failed to develop timely baseline care plans for two residents, one with a high fall risk and another with severe cognitive impairment. The first resident did not receive a fall care plan within 48 hours of admission, resulting in a fall 20 days later. The second resident's representative was not provided with a care plan summary or involved in goal-setting discussions, despite the resident's cognitive impairment. Staff interviews confirmed the requirement for timely care plans, but an urgent issue delayed the process for the second resident.
The facility failed to develop comprehensive care plans for two residents, one with dementia and behavioral disturbances and another with PTSD. The care plans did not address specific needs such as cognitive impairment, behavioral symptoms, and trauma-informed care, leading to deficiencies in meeting the residents' individual needs.
The facility failed to adhere to physician orders and document care for two residents. One resident did not have blood sugar levels documented as ordered, lacked a physician's order for catheter care, and had an improperly scheduled voiding trial. Another resident's continuous glucose monitoring sensor was not changed every 14 days as recommended, and there was no physician's order for this change.
A resident with Alzheimer's and language barriers was not provided adequate communication support in a facility. Despite a care plan for translation services, staff were unaware of resources, relying on gestures and family for communication. A Greek-speaking physician was available only for medical issues, and a translation binder was outdated, leading to a deficiency in person-centered care.
A resident with dementia was not provided with adequate activities to meet their needs, as outlined in their care plan. Despite being severely cognitively impaired, the resident's activity participation was limited to TV/radio and family visits, with little engagement in structured activities. Observations and staff interviews confirmed the lack of staff engagement, even when group activities were available.
The facility failed to conduct quarterly smoking evaluations for two residents with cognitive impairments and diagnoses of bipolar disorder and anxiety. Despite being observed smoking under supervision, their assessments were not completed as required by the facility's policy, leading to a deficiency in ensuring residents were free from accident hazards.
A facility failed to monitor adverse consequences of anticoagulant medication for a resident with atrial fibrillation and hypertension. Despite receiving Rivaroxaban as ordered, the resident's medical record lacked documentation of monitoring for adverse effects, contrary to the facility's protocol. Staff interviews confirmed the necessity of such monitoring, highlighting a lapse in protocol adherence.
A facility failed to limit the use of a PRN antipsychotic medication for a resident with Alzheimer's disease to 14 days, as required by their policy. The medication, Quetiapine, was ordered indefinitely without re-evaluation or documented rationale for extended use. Interviews with staff confirmed the oversight, highlighting a lapse in adherence to the facility's guidelines for antipsychotic medication management.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure proper communication between the nursing facility and the dialysis center for a resident with end-stage renal disease and diabetes mellitus. The resident, who was cognitively intact, required dialysis treatments three times a week. However, the facility did not complete the necessary dialysis communication forms from October 2023 through August 2024, as evidenced by the absence of these forms in the dialysis communication book. This lack of documentation was confirmed during interviews with the Unit Manager and Nurse #2, who acknowledged that the forms were not completed as required. The facility's Long Term Care Facility Outpatient Dialysis Services Agreement outlined the need for appropriate medical and administrative information to accompany residents during transfers to the dialysis center. Despite this requirement, the facility did not maintain ongoing communication with the dialysis center, as noted by the dialysis nurse, who stated that communication forms were not regularly completed unless something unusual occurred with the resident. This deficiency highlights a failure to adhere to professional standards of practice for dialysis care and services.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. During an inspection, surveyors observed that food items in two refrigerators in the main kitchen were not properly labeled with use-by dates. Specifically, a large package of American cheese and a bowl of egg salad in Refrigerator #1, and a container of feta cheese and a bag of parmesan cheese in Refrigerator #2, were found without appropriate labeling. The Food Service Manager (FSM) acknowledged that the kitchen staff did not follow the facility's policy requiring food items to be labeled with an opened and use-by date. In addition to the main kitchen, the facility's nourishment kitchenettes on the second and third floors also exhibited deficiencies in food labeling and storage. Surveyors found multiple food items, including apple juice, applesauce, and various take-out containers, without resident names or use-by dates in the second-floor kitchenette. Similarly, the third-floor kitchenette contained unlabeled items such as hot sauce, chicken noodle soup, and fast-food items. The FSM confirmed that these items should have been labeled with the resident's name and use-by date, and any unlabeled items should be discarded. Furthermore, the third-floor kitchenette refrigerator was found to be dirty, with spills and splashes of liquid substances on the shelves and sides. Containers of food were placed on top of these spills, indicating a lack of proper sanitation practices. The FSM stated that the dietary aides were responsible for cleaning the kitchenette and refrigerator before restocking snacks and beverages. The facility's Dietary Morning Checklist also outlined the need for checking and discarding expired items, as well as ensuring proper labeling and dating of resident food, which was not adhered to in this instance.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed in advance and given the necessary information to make healthcare decisions regarding psychotropic medications. Specifically, for one resident, the facility did not provide complete information on the consent form for Bupropion, a psychotropic medication. The consent form lacked details about the dose administered, the benefits of the medication, and the correct dose range, which should have included the total daily dose of 225 mg that the resident was receiving. The resident involved was admitted with diagnoses including dementia with behavioral disturbance and bipolar disorder. Despite being cognitively intact, as indicated by a BIMS score of 13 out of 15, the resident's Health Care Proxy was activated. The psychotropic consent form, signed by the Health Care Proxy, failed to accurately reflect the medication's dose and benefits, and the dose range was incorrectly listed as 0-200 mg instead of up to 225 mg. This oversight was confirmed during an interview with the Unit Manager and a nurse, who acknowledged the discrepancies in the consent documentation.
Failure to Notify Physician of Antibiotic Recommendation
Penalty
Summary
The facility failed to notify the Physician/Practitioner of a change in treatment for a resident with a Stage 4 pressure ulcer. The Wound Consultant recommended the initiation of the antibiotic Augmentin, but this recommendation was not communicated to the Physician/Practitioner. As a result, the resident did not receive the prescribed antibiotic treatment. The resident was admitted with a Stage 4 pressure ulcer on the right calf, and the Wound Consultant's evaluation indicated the need for Augmentin 875 mg twice daily for seven days. The review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no indication that the antibiotic was administered. Interviews with the Unit Manager, Infection Control Nurse, and the Wound Consultant confirmed that the recommendation was not communicated to the Physician/Practitioner. The Physician and their Practitioner were unaware of the recommendation, and Nurse #7, who conducted wound rounds with the Wound Consultant, did not recall the recommendation. The Infection Control Nurse stated that all recommendations should be communicated to the Physician/Practitioner.
Improper Use of Resident Lounge as Storage Area
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for residents in one of its nursing units, specifically the C Unit Lounge. Observations made by surveyors over several days revealed that the lounge was being used to store various resident wheeled positioning devices, such as standard wheelchairs, high back wheelchairs, Broda chairs, mattresses, rolling walkers, and leg rests. These items were consistently observed in the lounge at different times of the day, indicating that the space was being used as a storage area rather than a resident activity or relaxation area. Interviews with residents, a resident representative, and facility staff confirmed the inappropriate use of the C Unit Lounge. A resident expressed that the lounge felt more like a storage room and was not welcoming or inviting. A resident representative echoed this sentiment, noting the room's heavy occupation by equipment. Facility staff, including an Activities Assistant, a CNA, a nurse, and the Maintenance Director, acknowledged that the lounge was used to store equipment not currently in use to keep resident rooms less cluttered. The Administrator admitted that while wheelchairs were stored in the lounge when not in use, unassigned equipment and mattresses should not have been stored there.
Failure to Develop Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop a baseline or comprehensive care plan within 48 hours of admission for two residents, leading to deficiencies in providing effective and person-centered care. For one resident, who was legally blind and had epilepsy, the facility did not establish a baseline care plan related to falls, despite the resident being assessed as a high fall risk with a score of 19. This oversight resulted in the resident experiencing a fall 20 days after admission, with the care plan for falls only being established on the day of the incident. For another resident with dementia and behavioral disorders, the facility did not provide the resident or their representative with a summary of the baseline care plan within the required timeframe. The resident was severely cognitively impaired, and the representative reported not having discussed the resident's goals or plan of care with the facility since admission. Despite a family member being present daily, the facility did not initiate a meeting to establish the resident's goals or treatment plan, and the representative was not included in the baseline care plan meeting. Interviews with facility staff confirmed that baseline care plans should be developed within 48 hours of admission, and a summary should be provided to the resident or their representative. However, in the case of the second resident, the social worker admitted that the baseline care plan meeting had not occurred as initially reported due to an urgent issue at the facility, and the representative was not contacted until several days after admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #35, who was admitted with diagnoses of dementia with behavioral disturbance and psychotic disorder with delusions, did not have a care plan that addressed their impaired cognition and behavioral disturbances. Despite the resident's cognitive impairment and behavioral symptoms being triggered in the Minimum Data Set (MDS) assessment, the care plan only focused on the use of psychotropic medications without addressing the resident's specific cognitive and behavioral needs. Resident #35's care plan lacked specific interventions for managing the resident's dementia-related behaviors, such as agitation, yelling, and refusal of medication. The care plan did not include target behaviors for monitoring or strategies to address the resident's cognitive loss and behavioral symptoms. Progress notes indicated ongoing issues with agitation and confusion, yet these were not adequately reflected in the care plan, highlighting a gap in the facility's approach to managing the resident's condition. Similarly, Resident #52, who was admitted with diagnoses including dementia, anxiety disorder, major depressive disorder, and chronic PTSD, did not have a trauma-informed care plan. The facility's policy required a specific plan of care for residents with a history of trauma, but this was not completed for Resident #52. The social worker and unit manager acknowledged the absence of a care plan addressing PTSD triggers, indicating a failure to provide appropriate care for the resident's mental health needs.
Deficiencies in Adherence to Physician Orders and Documentation
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For Resident #35, the facility did not ensure that fingerstick blood sugar levels were obtained at the times specified by the physician's order. Although the fingersticks were performed daily, the values were not documented on the Medication Administration Records (MAR) as required. Additionally, the facility did not have a physician's order for the care and maintenance of the resident's catheter drainage bag, nor was there documentation of the bag being changed, despite the resident having a history of urinary tract infections. Furthermore, the facility did not implement a voiding trial for Resident #35 as ordered by the physician. The voiding trial was scheduled for a specific date, but there was no documentation that it was attempted on that date, nor was there communication with the physician to reschedule it. Instead, the trial was conducted on a different date without a corresponding physician's order, and the resident's catheter was reinserted after the trial failed. For Resident #63, the facility did not have complete physician's orders for the management of a continuous glucose monitoring sensor. The orders did not include instructions to change the device every 14 days as recommended by the manufacturer. The medical record lacked documentation that the sensor was changed according to these guidelines, and the unit manager confirmed the absence of a necessary physician's order for the sensor change.
Failure to Provide Language Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident who primarily speaks Albanian and Greek. The resident, diagnosed with Alzheimer's disease, major depressive disorder, and adjustment disorder, was admitted in May 2019. Despite the care plan indicating the need for a language translator, the facility did not implement effective communication strategies, leaving the resident unable to communicate effectively with staff who did not speak Albanian or Greek. Observations and interviews revealed that staff were unaware of available resources to assist in communication, such as a language translation service or communication book. The resident's health care proxy and staff confirmed the absence of these resources, and staff resorted to using hand gestures or relying on family members for translation. A Greek-speaking physician was available for medical translations, but not for non-medical communication needs. The surveyor's inspection of the nursing station and surrounding areas found no communication aids or information about translation services. A binder labeled for Greek translation was discovered, but it contained outdated information, with most listed translators no longer working at the facility. This lack of accessible communication resources and staff awareness contributed to the deficiency in providing person-centered care for the resident.
Failure to Provide Adequate Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities tailored to meet the interests and support the well-being of a resident diagnosed with dementia and behavioral disorders. The resident, who was admitted in August 2024, was severely cognitively impaired, as indicated by a BIMS score of 0 out of 15. Despite the care plan interventions that included encouraging participation in daily activities and providing 1:1 visits if unable to attend group events, the resident's activity participation record showed limited engagement, primarily involving TV/radio and family visits, with minimal involvement in structured activities. Observations by surveyors over several days revealed that the resident often remained in their room without staff engagement, even when group activities were occurring nearby. Interviews with staff and the resident's representative confirmed that the resident was not being actively engaged in activities, contrary to the care plan's goals. The Activities Director acknowledged the lack of recorded participation in activities, despite the resident's care plan indicating a need for routine involvement in activities to meet their emotional, intellectual, physical, and social needs.
Failure to Conduct Quarterly Smoking Evaluations
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards by not completing quarterly smoking evaluations for two residents. Resident #32, who was admitted in June 2020 with diagnoses including bipolar disorder and anxiety, was observed smoking in the designated area with staff supervision. The resident's last smoking and safety assessment was conducted on 12/18/23, and no further assessments were recorded after this date, despite the facility's policy requiring quarterly evaluations. Similarly, Resident #62, admitted in March 2021 with similar diagnoses, was also observed smoking under supervision. The resident's medical record showed smoking and safety assessments were conducted on 1/20/23, 6/16/23, 4/1/24, and 7/1/24, but missed the required quarterly assessments in 4/2023, 9/2023, 12/2023, and 3/2024. During an interview, Unit Manager #2 acknowledged that some assessments were missed and not completed quarterly for these residents.
Failure to Monitor Anticoagulant Adverse Effects
Penalty
Summary
The facility failed to monitor adverse consequences of anticoagulant medications for a resident with atrial fibrillation and hypertension. The resident was admitted in January 2024 and was receiving Rivaroxaban, an anticoagulant medication, as per the physician's orders. However, the medical record did not indicate any monitoring for adverse consequences of the medication, which is a requirement according to the facility's Anticoagulation-Clinical Protocol. Interviews with various staff members, including nurses and the Staff Development Coordinator, confirmed that residents on anticoagulant medications should be monitored for adverse consequences every shift. Despite this, there was no order in place for such monitoring for the resident in question, indicating a lapse in adherence to the facility's policy and protocol for managing anticoagulant therapy.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not limit the use of an as-needed antipsychotic medication, Quetiapine, to 14 days or provide a documented clinical rationale and duration for extending its use beyond this period. The facility's policy on antipsychotic medication use, revised in July 2022, mandates that PRN orders for such medications should not be renewed beyond 14 days without a healthcare practitioner's evaluation and documentation of the rationale for continued use. The resident in question was admitted with a diagnosis of Alzheimer's disease and had a physician's order for Quetiapine to be administered as needed for breakthrough aggression and agitation. However, the order was listed as indefinite, and there was no evidence in the medical record that the medication was re-evaluated after 14 days. Interviews with the Unit Manager and Staff Development Coordinator confirmed that the order should have been limited to 14 days, and the physician should have re-evaluated the medication thereafter.
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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