Hermitage Healthcare (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 383 Mill Street, Worcester, Massachusetts 01602
- CMS Provider Number
- 225009
- Inspections on file
- 15
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Hermitage Healthcare (the) during CMS and state inspections, most recent first.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as observed by surveyors.
A facility did not update its Facility Assessment after admitting a resident with a laryngectomy tube, failing to identify the need for specialized care, staff training, and equipment for airway management. The assessment did not reflect the new care requirements, despite documentation in the resident's medical records and acknowledgment by facility leadership.
A resident with severe dementia, anxiety, and vision impairment was repeatedly left unsupervised during meals, despite requiring continuous supervision and assistance. The resident was observed eating with a comb and fork, spilling food and drink on themselves and their surroundings, and not receiving the appropriate utensils or support. Staff were unclear about the resident's care needs, and the DON confirmed these incidents were dignity concerns.
A resident with a history of falls and muscle weakness was repeatedly observed without access to a functioning call light, as the device was left hanging behind the bed and out of reach. Staff interviews confirmed the call light's clip was broken and that the resident was unable to call for assistance, contrary to facility policy and the resident's care plan.
Two residents did not receive care according to professional standards: one did not have the prescribed wound cleansing solution used for an arterial ulcer, and another had a urinary catheter size changed during a urology consult without the physician's orders being updated to reflect the new size. Nursing staff and the DON confirmed that facility policies and physician orders were not followed in both cases.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A resident with sensorineural hearing loss did not receive a recommended hearing aid due to the facility's lack of follow-up with the audiology office. Despite an evaluation confirming the need for a hearing aid and consent for services, the resident remained without the device, continued to experience hearing difficulties, and expressed a desire for further assistance. Facility staff did not ensure the hearing aid was ordered or received, and no additional follow-up was conducted after the initial appointment.
Nursing staff did not receive training or competency assessments specific to laryngectomy tube care for a resident admitted with this condition. Multiple nurses were unable to distinguish between tracheostomy and laryngectomy care, and the facility lacked policies and documentation addressing the unique needs of residents with laryngectomy tubes.
Surveyors identified that two residents did not receive their prescribed medication doses as ordered, resulting in a medication error rate of 11%. In both cases, nurses administered lower doses than ordered and inaccurately documented the administration in the MAR, contrary to facility policy.
The facility did not ensure that all staff completed mandatory annual Resident Rights training, with 35 staff members found out of compliance. The SDC lacked a tracking system for monitoring education completion, and the facility did not have a policy on the frequency of mandatory education. The DON confirmed the deficiency after reviewing staff education records.
The facility did not provide written transfer and bed-hold notifications or notify the Ombudsman when several residents, including those with cognitive impairment or legal representatives, were transferred to the hospital. Record review and staff interviews confirmed the absence of required documentation for these notifications.
A resident with cataracts and a prescription for eyeglasses was inaccurately coded on the MDS assessment as not using corrective lenses, despite optometry records, resident statements, and direct observation confirming eyeglass use. The error was acknowledged by the MDS nurse, who attributed it to a float staff member completing the assessment.
A resident's enteral tube feeding equipment was found unclean, with multiple stains and dried brown material, despite facility policies requiring regular cleaning. Observations revealed a lack of communication between nursing and housekeeping staff regarding cleaning responsibilities, leading to the deficiency.
A resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger did not receive recommended surgical intervention due to the facility's failure to arrange follow-up services. Despite being assessed as cognitively intact, the resident's surgical needs were not communicated to the physician or health care proxy. Facility staff were unaware of the surgical recommendation, and the occupational therapist was unable to contact the hand specialist, resulting in the resident not receiving the necessary surgery.
A resident with a history of trauma, including unspecified adult maltreatment and cognitive impairment, was admitted without a trauma-informed care plan. Despite hospital records indicating severe trauma, the facility did not develop or implement a care plan addressing the resident's needs, leading to ineffective management of behaviors such as wandering and care rejection. A social worker admitted the oversight.
Two residents with dementia experienced an undignified situation when one resident verbally abused the other during personal care. The facility staff failed to monitor and document these behaviors, and did not implement effective interventions to prevent the verbal abuse, leading to a deficiency in providing dignified care.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Update Facility Assessment for Laryngectomy Tube Care Needs
Penalty
Summary
The facility failed to update its Facility Assessment following the admission of a resident with a laryngectomy tube, despite this representing a change in the resident population not previously identified in the assessment. The resident was admitted with diagnoses including dementia and a laryngectomy tube, requiring specialized care and equipment for airway management, particularly in the event of cardiopulmonary arrest. The hospital discharge summary and nurse practitioner progress note both documented the presence of a laryngectomy tube and the need for full code status. A review of the Facility Assessment, last updated in July 2025, showed that while it included information on residents with respiratory failure and those requiring oxygen therapy, suctioning, tracheostomy care, ventilator or respirator care, and BIPAP/CPAP, it did not specifically identify residents needing laryngectomy tube care. The assessment also lacked documentation of staff training, competencies, or specialized equipment necessary for managing laryngectomy tubes. During interviews, facility leadership acknowledged that the assessment had not been updated to reflect the needs of residents with laryngectomy tubes after the resident's admission.
Failure to Ensure Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe unspecified dementia, anxiety, and bilateral cataracts was not treated with respect and dignity during mealtimes. The resident, who had highly impaired vision, severely impaired decision-making, and required supervision or assistance with eating, was observed eating alone in their room during multiple meals. The resident attempted to eat using a comb and a fork, resulting in food being spilled on themselves, the tray, the tray table, and the floor. The resident's care plan and Kardex indicated a need for continuous supervision during meals due to their cognitive and visual impairments, but this supervision was not provided. During one lunch observation, the resident was left alone and used a comb and fork to eat, leading to significant difficulty and mess. The resident was seen stabbing at food with the comb and fork, dropping food on the floor and themselves, and mixing chewed food with other meal items. The Activities Director discovered the resident in this state, located the proper eating utensil, and removed the comb, but the resident had already experienced a lack of dignity and appropriate assistance during the meal. Staff interviews revealed confusion about the resident's care needs, with the assigned CNA unaware of the specific requirements for supervision and the nurse confirming that the Kardex did require continuous supervision. Further observations showed the resident eating breakfast and lunch alone on other occasions, with food and drink being spilled due to lack of assistance. The Director of Nursing acknowledged that such incidents, including eating with a comb and spilling food, would be considered dignity concerns. The failure to provide the required supervision and appropriate utensils during meals resulted in the resident not being treated with the respect and dignity guaranteed by facility policy and federal and state laws.
Failure to Ensure Resident Access to Call Light System
Penalty
Summary
Facility staff failed to provide reasonable accommodation for a resident by not ensuring the call system was within the resident's reach, as required by facility policy and the resident's care plan. Multiple observations over two days showed the call light hanging on the wall behind the resident's bed, inaccessible to the resident both while lying down and sitting up. The resident, who had a history of falls, muscle weakness, and anxiety disorder, confirmed during an interview that they were unable to reach the call light and had to resort to yelling for assistance. Staff interviews revealed awareness of the issue, with a CNA noting that the call light's clip was broken and should be fixed to allow it to be attached to the bed. The CNA acknowledged that the lack of access to the call light would cause the resident distress and prevent them from calling for help. The DON also confirmed that the resident should have access to the call light at all times and that staff are responsible for ensuring it is within reach.
Failure to Follow Physician Orders for Wound Care and Catheter Management
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a right heel arterial ulcer, the facility did not implement the wound consultant's recommendation to use a specific wound cleansing solution (Vashe) as ordered by the physician. Instead, a nurse used normal saline to cleanse the wound, despite the physician's order and wound care specialist's notes specifying the use of Vashe. The nurse acknowledged during an interview that the correct solution was not used and that normal saline does not have antibacterial properties, which was contrary to the wound care plan and facility policy. For another resident with a history of urinary retention and a Foley catheter, the facility failed to ensure that physician's orders were updated to reflect a change in catheter size following a urology consult. The resident returned from the consult with a different size catheter (18 Fr Coude) than what was documented in the physician's orders (16 Fr/10 ML). Nursing staff and the DON confirmed during interviews that the orders should have been updated to match the catheter size inserted during the consult, but this was not done. The discrepancy was identified during a review of the resident's medical record and direct observation of the catheter in place. Both deficiencies were identified through observation, record review, and staff interviews. The facility's policies required verification of physician's orders and adherence to specific procedures for wound care and catheter management, but these were not followed in the cases described. The failures involved not following wound care recommendations and not updating medical orders to reflect changes in treatment, as required by professional standards and facility policy.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Recommended Hearing Aid to Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident with sensorineural hearing loss received a recommended hearing aid, as identified through observations, interviews, and record reviews. The resident, who was admitted with left ear hearing loss and had a care plan noting impaired communication, underwent an audiological evaluation that confirmed significant hearing impairment and recommended a hearing aid. Although consent for audiology services was obtained and the process to acquire a hearing aid was initiated, there was no documented follow-up by the facility to confirm the order or ensure the device was received. The resident remained without a hearing aid, continued to experience hearing difficulties, and expressed a desire to see someone about his hearing. Interviews revealed that the facility's staff believed the audiology office would contact them once the hearing aid arrived, but no further contact was made after the initial appointment. The unit manager later discovered that the hearing aid had not been ordered as previously thought, and no additional follow-up occurred. The resident's legal guardian indicated willingness to purchase the hearing aid if needed but noted that the facility did not pursue the audiologist's recommendations. Facility policy required staff to assist residents with appointments and follow-up care, but this was not carried out for this resident.
Lack of Staff Competency for Laryngectomy Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to care for a resident with a laryngectomy tube. Specifically, the facility's assessment did not identify any residents requiring laryngectomy tube care, nor did it indicate that staff had received training or competency evaluations for this type of care. Multiple nurses, including those regularly assigned to the resident, were unable to distinguish between a tracheostomy and a laryngectomy, and reported not receiving any specific training or competency assessment related to laryngectomy tube care. The Assistant Director of Nurses, who also served as the Staff Development Coordinator, confirmed that while tracheostomy care training had been provided, no such training or competency assessment existed for laryngectomy care, and there was no facility policy addressing this need. The resident in question was admitted with a laryngectomy tube and Alzheimer's Dementia. Interviews with nursing staff and the resident's physician revealed a lack of awareness and understanding regarding the resident's specific airway needs. The physician was unaware of the difference in stoma type and expected that staff would have received appropriate training and that necessary equipment would be available. The absence of staff training, competency assessment, and facility policy for laryngectomy care directly contributed to the deficiency identified during the survey.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, resulting in an observed error rate of 11% during the survey. For one resident with asthma, the nurse administered only one puff each of Budesonide-Formoterol Fumarate and Spiriva Respimat inhalers, despite physician orders specifying two puffs of each medication. The nurse also documented in the Medication Administration Record (MAR) that two puffs of each medication were given, which did not match the observed administration. The nurse acknowledged the discrepancy and recognized that the medications were not administered as ordered. In a separate incident, another resident with dysphagia and gastro-esophageal reflux disease was ordered to receive two capsules of Omeprazole DR 20 mg daily. However, the nurse administered only one capsule and documented in the MAR that two capsules were given. The nurse later confirmed that only one capsule was administered and that this did not follow the physician's order. These actions were inconsistent with the facility's medication administration policy, which requires verification and administration of medications as prescribed.
Failure to Ensure Annual Resident Rights Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff members received annual training on Resident Rights, as required. According to the Annual All Employee Course Completion History Report, 35 staff members were not in compliance with the mandatory annual Resident Rights education as of the review date. The Staff Development Coordinator (SDC) acknowledged responsibility for staff education but admitted there was no tracking system in place to monitor compliance with mandatory education requirements. The SDC also confirmed that Resident Rights education should be completed upon hire and annually by all staff. The Director of Nurses (DON) confirmed that many staff were out of compliance with the required training after reviewing the course completion report. The Administrator stated that the facility did not have a policy specifying the frequency of mandatory education. The DON emphasized the importance of Resident Rights education for staff to be properly trained to care for residents. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to transfer, discharge, bed-hold policies, and Ombudsman notification for four residents out of a sample of twenty. Specifically, the facility did not issue written transfer and bed-hold notices to the appropriate resident representatives or notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was confirmed through record review and staff interviews, which revealed the absence of documentation for these notifications in the clinical records of the affected residents. For one resident with a legal guardian, there was no evidence that the guardian received written notice of the hospital transfer or bed-hold policy, nor that the Ombudsman was notified. Another resident with a health care proxy also lacked documentation of written transfer and bed-hold notifications to the proxy and notification to the Ombudsman. In a third case, the record did not show that the Ombudsman was notified of the resident's hospital transfer. For a fourth resident, who was severely cognitively impaired, there was no evidence that transfer and bed-hold notifications were provided or that the Ombudsman was informed when the resident was sent to the hospital. Interviews with the social worker responsible for these notifications confirmed that the facility did not have a specific policy for bed-hold, transfer, and Ombudsman notification, and that federal regulations should have been followed. The social worker was unable to provide evidence that the required notifications were sent for any of the four residents involved in the deficiency.
Inaccurate MDS Coding for Corrective Lenses Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the use of corrective lenses during the observation period. The resident, who had a history of hypertensive chronic kidney disease, essential primary hypertension, and falls, was documented in optometry evaluations as having cataracts and requiring eyeglasses with a specific prescription. Despite this, the MDS assessment indicated that the resident did not use corrective lenses, and that the resident had adequate vision. Interviews and observations confirmed that the resident used eyeglasses, with the resident stating they wore glasses and had been advised by an eye doctor about the need for cataract surgery. The surveyor observed the resident's eyeglasses on the bedside table, and the MDS nurse acknowledged that the assessment was coded in error, attributing the mistake to a float staff member who completed the assessment. The nurse confirmed that the resident could not see without their glasses and that the MDS should have reflected the use of corrective lenses.
Failure to Maintain Clean Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident residing on the Sunburst Unit. Specifically, the resident's enteral tube feeding equipment, including a pump and a pole, was observed to be unclean. The facility's policy for Cleaning and Disinfection of Environmental Surfaces, last revised in April 2018, requires that semi-critical items, which come in contact with mucous membranes or non-intact skin, should be free from all microorganisms. Additionally, housekeeping surfaces are to be cleaned regularly, when spills occur, and when visibly soiled. Despite these guidelines, the surveyor observed multiple stains and dried brown material on the resident's feeding tube pump and pole on two separate occasions. During an observation and interview, Nurse #1 acknowledged that the resident's tube feeding supplies should not have been soiled and should have been cleaned. Nurse #1 indicated that the housekeeping staff were responsible for cleaning the surfaces in the resident's room. However, Housekeeping Staff #1 stated that she had not been informed about the soiled tube feeding supplies and mentioned that both housekeeping and nursing staff were responsible for keeping these items clean. This lack of communication and adherence to cleaning protocols led to the deficiency in maintaining a clean environment for the resident.
Failure to Arrange Surgical Services for Resident with CTS and Trigger Finger
Penalty
Summary
The facility failed to arrange necessary surgical services for a resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger, as recommended by a hand surgeon. The resident, who was admitted with Type 2 Diabetes and wrist pain, was diagnosed with moderate right CTS through an electromyography (EMG) test. The hand surgeon recommended surgery for the resident's right carpal tunnel and trigger finger, but the facility did not arrange for the follow-up with the surgeon. The resident, who was initially deemed incapacitated due to moderate progressive dementia, was later assessed as cognitively intact. Despite this, the facility did not communicate the surgical recommendation to the resident's physician or health care proxy (HCP). The resident expressed ongoing pain and difficulty with hand movement, indicating that the problem persisted without resolution. The resident reported that pain medication was provided but did not address the underlying issue, and the resident had not received any updates regarding the surgery. Interviews with facility staff revealed a lack of awareness and communication regarding the surgical recommendation. Nurse #2 was unaware of the surgery recommendation and believed the resident's condition was being managed with medication for arthritis. The occupational therapist, who evaluated the resident, attempted to contact the hand specialist but was unable to obtain necessary information from the nursing staff or the resident's family. This lack of coordination and follow-up resulted in the resident not receiving the recommended surgical intervention.
Failure to Implement Trauma-Informed Care Plan for Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident who was a trauma survivor. The resident, admitted in February 2024, had a history of unspecified adult maltreatment, cognitive impairment, and depression. Hospital discharge paperwork indicated the resident was a victim of nonconsensual sexual intercourse, leading to an Elder At-Risk report. The resident also had a right humerus fracture and multiple rib fractures. Despite these significant trauma indicators, the facility did not develop or implement a trauma-informed care plan for the resident. The resident's care plans did not include trauma-informed care, although there was a behavior care plan addressing wandering, exit-seeking, screaming, anger, disruptive sounds, and care rejection. The facility's attempts to manage these behaviors through interventions were ineffective. A social services evaluation confirmed the resident's trauma history and the absence of a trauma-informed care plan. During an interview, a social worker acknowledged the oversight in not completing the necessary care plan for the resident.
Failure to Address Verbal Behaviors in Dementia Patients
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, leading to an undignified experience for both. Resident #49, who has a history of traumatic brain injury, major depressive disorder, and dementia, was observed to be agitated and resistant to care, frequently yelling and crying during personal care. Resident #48, also diagnosed with dementia with agitation, exhibited verbal behaviors such as yelling and swearing at Resident #49 during these times, which were not adequately monitored or addressed by the facility staff. On the day of the surveyor's observation, Resident #48 was seen yelling at Resident #49, who was crying out in pain during personal care. Despite being alerted to the situation, Nurse #2 did not address Resident #48's verbal behaviors, and the behavior was not recorded in the facility's records. The staff failed to implement effective behavior interventions to prevent Resident #48 from directing verbal behaviors towards Resident #49, resulting in a lack of dignity and respect for both residents. The facility's process for behavior monitoring was not followed, as staff did not record the observed behaviors and interventions in the electronic health record. The Director of Nursing confirmed that the behaviors should have been documented and discussed in the facility's weekly Risk Meeting, but this did not occur. The lack of documentation and discussion of Resident #48's behaviors indicates a failure in the facility's process for monitoring and addressing resident behaviors, contributing to the deficiency.
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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