Highland Park Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chelsea, Massachusetts.
- Location
- 255 Central Avenue, Chelsea, Massachusetts 02150
- CMS Provider Number
- 225557
- Inspections on file
- 19
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Highland Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Multiple residents did not receive care in accordance with professional standards, including missed or undocumented weekly skin assessments, lack of physician orders for pressure-relieving devices, failure to apply ace wraps and palm guards as ordered, and incorrect transcription of medication orders for a resident who was NPO. Staff interviews confirmed that these actions did not align with physician orders or facility policy.
The facility did not address monthly pharmacist MRR recommendations in a timely manner for three residents, resulting in significant delays in obtaining recommended lab tests such as A1C, BMP, CBC, and lipid panels. Nursing staff and the DON confirmed that recommendations should be promptly reviewed and acted upon, but in these cases, there was no documentation explaining the delays or reasons for not following the pharmacist's advice.
The facility did not maintain an active infection control surveillance plan, with incomplete and outdated infection tracking records. During wound care for a resident with pressure ulcers, staff failed to wear required precaution gowns and did not consistently perform hand hygiene after glove removal, contrary to facility policy. The DON was unable to provide updated infection surveillance information and was unfamiliar with the surveillance documentation process.
Two residents with limited English proficiency did not receive care in a manner that promoted their dignity and individuality, as staff failed to consistently use interpreter services or communication aids as required by facility policy. Staff were observed not engaging with these residents in their primary languages, and documentation did not show that interpreters were used during significant care events, such as post-fall assessments.
Three residents were not provided with the opportunity to choose alternate meals, as menus were not distributed and staff did not consistently inform or ask residents about meal preferences. Some residents were unaware of menu postings due to limited mobility, and requests for alternate meals were often denied or ignored due to communication issues with the kitchen. Staff interviews confirmed that meal options were not routinely communicated, and there was no policy in place to ensure residents could exercise their right to meal choice.
A resident with multiple medical conditions had inconsistent documentation regarding code status, with some records indicating full code and others DNR/DNI. Staff interviews revealed confusion and lack of communication about the resident's advance directives, and required discussions with the responsible party were not conducted. The resident's medical record also contained a blank MOLST form, reflecting a failure to ensure proper documentation and review of advance directives.
Two residents with limited English proficiency did not receive accurate MDS cognitive assessments because interpreter services were not utilized, despite facility policy and RAI guidelines requiring assessments in the resident's preferred language. Staff did not attempt to use interpreters, and the assessments were marked as unable to be completed due to communication barriers.
Two residents did not receive necessary assistance with personal hygiene, including nail care and oral hygiene, despite care plans indicating their need for staff support. One resident was observed with long, dirty fingernails, while another reported not having a toothbrush and showed signs of poor oral hygiene. Staff and documentation confirmed that required care and supplies were not provided, and residents did not refuse care.
A resident with chronic pain and osteoarthritis did not receive recommended OT evaluation for hand splints, Voltaren gel for pain, or a rheumatology referral after an orthopedic consult. The specialist's recommendations were not communicated or documented in the medical record, and the resident continued to report pain without the suggested interventions.
A resident with severe cognitive impairment and Stage III pressure injuries did not receive pressure ulcer care as ordered, including incorrect air mattress settings and failure to implement wound physician treatment recommendations. Nursing staff and the DON confirmed that wound care orders were to be followed, but the required treatments were not consistently documented or carried out.
A resident with severe cognitive impairment and upper extremity contracture did not receive a prescribed functional maintenance program after discharge from OT. Despite recommendations for a right hand roll to maintain function, the resident was repeatedly observed without the orthotic device, and the necessary orders were not transcribed or implemented by staff.
Two residents experienced deficiencies in safety and supervision: one was not assessed or investigated after a fall resulting in a left ankle fracture, and another, identified as an elopement risk, was left without a functioning wandergaurd bracelet for multiple days with no documented attempts to reapply it or implement alternative interventions. Staff and DON interviews confirmed lapses in following facility policies for incident investigation and elopement prevention.
Two residents requiring dialysis care did not receive services consistent with professional standards, as staff repeatedly took blood pressures from arms with AV fistulas despite physician orders and care plans prohibiting this practice. Additionally, the facility failed to maintain proper communication with the dialysis center for one resident, with inconsistent documentation and lack of care plan updates regarding the resident's refusal to take the communication book.
Surveyors found that a treatment cart containing prescription ointments and biologicals was left unlocked and unattended on two occasions. Interviews with nursing staff and the DON confirmed that the cart should have been locked when not in use, but this procedure was not followed.
Staff failed to maintain accurate medical records for three residents, including incorrect documentation of a palm guard application, inaccurate recording of ace wrap use, and lack of an appropriate diagnosis for a psychotropic medication. These actions resulted in discrepancies between care provided and what was documented in the medical records.
Two residents with dementia were not provided or offered required influenza and pneumococcal vaccinations, despite facility policy and documented consent. Immunization records showed that one resident had not received the current influenza vaccine and had not been offered it, while the other was not up to date on pneumococcal vaccination and had not received the current influenza vaccine, with no reason documented. The DON/IP confirmed the expectation for annual and eligibility-based vaccination but could not account for the missed immunizations.
A resident with dementia who was not up to date on COVID-19 vaccination consented to receive the latest vaccine, but the facility did not administer it as required by policy. The DON/IP could not provide a reason for the missed vaccination.
The facility did not issue the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three residents who no longer qualified for Medicare Part A skilled services and had not used all their benefit days. As a result, these residents or their representatives were not informed about the discontinuation of Medicare coverage or their potential financial liability for continued skilled services. The Regional MDS Nurse confirmed that ABN notices were not being provided as required.
The facility failed to maintain sufficient staffing levels to meet residents' personal care needs, as evidenced by a review of working schedules showing inadequate staffing for 122 consecutive days. The Administrator acknowledged that staffing issues were limiting facility admissions.
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. Despite the facility's policy requiring consents before administering such medications, residents with diagnoses including anxiety, PTSD, major depressive disorder, and severe cognitive impairment were given psychotropic drugs without the necessary consents. Staff interviews confirmed that the required consents were not obtained.
The facility failed to secure resident PHI on one of three nursing units. Multiple instances were observed where resident information was displayed on unattended nursing cart computers, visible to passersby, including other residents. The information included names, dates of birth, allergies, medications, vital signs, code status, and special instructions for treatment. The Director of Nursing confirmed that such information should not be exposed while unattended.
The facility failed to maintain a homelike environment on three resident care units, with issues such as lifting paint, scuffed doors, broken tiles, strong odors, and loose handrails. The Maintenance Director and DON acknowledged the problems but indicated a lack of immediate plans to address them.
The facility failed to report a verbal altercation between two residents and an allegation of abuse involving another resident. The incidents were not reported to the State Agency within the required timeframe, and staff did not follow the facility's policy on abuse prevention and reporting.
The facility failed to investigate an altercation between two residents and an allegation of abuse involving another resident. One resident reported a verbal altercation with another, which involved the police, but no investigation was initiated. Another resident felt humiliated by the Administrator's public instruction to wear a bra, and the incident was not reported or investigated due to fear of retaliation.
The facility failed to accurately code MDS assessments for four residents, including errors in documenting preferred language, hospice services, contractures, and antipsychotic medication administration. These inaccuracies were confirmed through observations, interviews, and record reviews.
The facility failed to ensure resident-centered care plans were implemented and/or developed for seven residents, including not using a right-hand grip splint, not supervising meals, not using booties for feet, not implementing fall prevention measures, not developing pain management and contracture care plans, and not creating personalized care plans for alcohol abuse and communication needs.
The facility failed to meet professional standards of nursing practice for four residents. One resident's refusal to take antipsychotic medication was not reported to the necessary medical staff, another resident's low blood sugar was not reported to the physician, a third resident did not receive a required occupational therapy evaluation, and a fourth resident's malfunctioning suprapubic catheter was improperly handled.
The facility failed to address the nutrition and hydration needs of three residents, leading to significant weight changes and insufficient fluid intake. One resident experienced a significant weight gain that was not timely identified, another had a significant weight loss due to lack of regular monitoring, and a third resident was not provided with sufficient fluids, leading to a risk of dehydration.
The facility failed to ensure that nursing staff received the necessary competencies and skill sets for resident care, including annual competencies for CNAs and licensed nurses, and specific training for suprapubic catheter care. This led to improper handling of a resident's catheter, resulting in the resident being sent to the hospital.
The facility failed to complete annual CNA performance reviews for three of six sampled CNAs. The Corporate SDC confirmed that these reviews should be done annually around the employees' anniversary hire date and kept in their files.
The facility failed to ensure proper medication storage and administration. A resident with moderate cognitive impairment was found with an unsupervised medication at their bedside, which was not documented. Additionally, medications on two medication carts and in two medication rooms were improperly labeled and stored, including undated inhalers and an unlocked Ativan box in the fridge. The DON confirmed that these practices did not meet the required standards.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. A cook contaminated saran wrap by holding it with her chin and resting it over her apron, then used it to cover food on the steam table. This was confirmed by the Food Service Director and another dietary staff member.
The facility failed to offer or provide education for the 2023-2024 COVID-19 vaccine to five residents, as required by its policy. Medical records lacked documentation of vaccine education, offering, or refusal, and some residents had signed consents only after the surveyor raised the issue. The Regional Infection Control Nurse and ADON acknowledged the oversight and had not yet ordered the vaccines for administration.
The facility failed to ensure that three of five CNAs reviewed completed the required 12 hours of in-service training within 12 months. The Corporate Administrator confirmed that the expectation is for all education to be completed yearly to ensure nursing staff competency.
The facility failed to ensure staff treated residents in a dignified manner during the dining experience. CNAs were observed standing over residents while providing meal assistance, contrary to the facility's policy on dignity. The DON confirmed that staff should be seated at eye level with residents during meal assistance.
A resident was moved to a new room without proper notice or consent, resulting in significant distress. The facility failed to follow its policy requiring verbal and written notice for room changes, and the new room was not adequately prepared.
A resident, who was cognitively intact, expressed frustration over having to wait up to a week to access $25.00 from personal funds. The facility required 48 hours notice for such requests, which the Business Office Assistant confirmed. The Administrator acknowledged that residents should have daily access to a realistic amount of their funds.
A resident experienced mental anguish and psychological distress after the Administrator publicly instructed them to wear a bra in a common area, despite the resident's discomfort with wearing one. Multiple staff members confirmed the Administrator's inappropriate handling of the situation, which embarrassed the resident.
The facility failed to implement its abuse policy and investigate allegations for two residents. One resident felt retaliated against after complaining about a nurse, and the accused nurse continued working during the investigation. Another resident felt humiliated by the Administrator's public demand to wear a bra, and staff did not report the incident due to fear of retaliation.
The facility failed to provide timely written notifications of transfer or discharge to the hospital for two residents, as required by policy. The clinical records lacked evidence of transfer/discharge notices, and interviews confirmed that the procedure was not followed.
The facility failed to complete a Significant Change in Status (SCSA) MDS assessment for a resident who elected to receive hospice care services. The resident, with severe cognitive impairment, initiated hospice services, but the required assessment was not completed within the 14-day timeframe. This was confirmed by the MDS Nurse.
The facility failed to update the behavior care plan for a resident with Dementia who prefers to sit in a pitch-black room, leading to staff difficulties in monitoring the resident. Interviews with staff confirmed the resident's behavior, but the care plan did not reflect this, despite the resident's history of falls and use of antipsychotic medications.
A resident with moderate cognitive impairments and multiple diagnoses did not receive scheduled showers for two weeks. Staff interviews and record reviews revealed that the CNA did not offer the showers and did not document any refusal of care, leading to a deficiency in providing necessary ADL assistance.
The facility failed to change a resident's dressing as per physician's orders, despite the dressing showing signs of blood on two consecutive days. The resident had a skin tear on the left hand, and the physician's order required daily dressing changes, which were not completed or documented properly.
A resident with severe cognitive impairments and a stage 4 pressure ulcer had their air mattress consistently set incorrectly, contrary to physician orders and care plan instructions. The mattress was set to 90 lbs instead of the resident's weight of 128.6 lbs, as observed over multiple days. Nursing staff and the DON confirmed the mattress should have been set according to the resident's weight.
The facility failed to store smoking materials safely for a resident with a traumatic brain injury and did not properly investigate and assess another resident after a fall resulting in hospitalization. Staff interviews confirmed non-compliance with safety protocols.
The facility failed to develop and implement trauma-informed care plans for two residents diagnosed with PTSD. Despite psychiatric evaluations confirming the PTSD diagnoses and physician's orders for medication, the residents' care plans did not include personalized PTSD care plans. The Social Worker confirmed that these care plans should have been developed in addition to the mood care plans.
The facility failed to re-evaluate a resident's psychotropic medication after 14 days of use, as required by policy. The Lorazepam order for a resident lacked an end date and was not re-evaluated by a physician, despite the resident being cognitively intact and having diagnoses including anxiety disorder and depression. The DON confirmed the need for a stop date and re-evaluation every 14 days.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 4 pressure ulcer, despite policy requirements. Observations showed no PPE in place, and staff interviews revealed a lack of awareness and education on EBP.
The facility failed to offer influenza vaccinations per CDC recommendations and facility policy for two residents. The facility did not document vaccine education, administration details, or refusals in the residents' medical records, leading to non-compliance with both CDC guidelines and internal policies.
Failure to Follow Physician Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that six residents received care in accordance with professional standards of practice, as evidenced by multiple deficiencies in following physician orders and documentation requirements. For two residents with cognitive impairments and at risk for pressure ulcers, nursing staff did not complete or properly document weekly skin assessments as ordered by the physician, despite marking them as completed on the Treatment Administration Record (TAR). There was no evidence in the electronic medical record or nursing progress notes that these assessments were performed or refused by the residents on the specified dates. Another resident was observed using an air mattress set to the highest setting, but there was no active physician order for the use of this pressure-relieving device, contrary to facility policy and staff expectations. Additionally, a resident with edema and intact cognition reported that his legs were not wrapped daily as ordered. Review of the TAR confirmed that the ace wrap treatment was not documented as completed on multiple dates, and staff interviews confirmed that lack of documentation meant the treatment was not implemented. Further deficiencies included a resident with hemiplegia who was not provided with a palm guard as ordered, with staff unable to locate the device and the resident stating it had not been worn for weeks. Another resident, who was NPO and had a feeding tube, had physician orders for oral medications transcribed incorrectly to be given by mouth, despite the NPO status. Staff interviews confirmed that these orders should not have been transcribed in this manner.
Delayed Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were addressed in a timely manner for three residents. For one resident with dementia and diabetes, the pharmacist recommended follow-up A1C testing on multiple occasions, but the test was not completed until 63 days after the initial recommendation. Another resident with dementia, diabetes, and other comorbidities had repeated pharmacist recommendations for BMP and CBC lab work, but the labs were not obtained until four months after the first recommendation. In both cases, there was no documentation in the medical record or pharmacy binder explaining the delay or providing a reason for not following the recommendations. A third resident with schizoaffective disorder and cerebral palsy had pharmacist recommendations for lipid panel and A1C testing over several months, but these labs were not completed until more than three months after the initial recommendation. Interviews with nursing staff and the DON confirmed that pharmacy recommendations are supposed to be reviewed and acted upon promptly, either by implementing them or documenting a physician's reason for not following them. However, in these cases, the recommendations were not addressed in a timely manner, and no explanations for the delays were found in the records.
Failure to Implement Infection Control Program and Adhere to Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required. Specifically, the facility did not maintain an active infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Review of the facility's infection control documentation revealed that the Monthly Infection Control Log (Line List) was incomplete for several months, with some sections left blank and no surveillance information recorded after March 2024. The Director of Nursing (DON), who also serves as the Infection Preventionist (IP), was unable to locate updated surveillance information and was unfamiliar with the surveillance binder, indicating a lapse in ongoing infection tracking and reporting. Additionally, staff failed to follow enhanced barrier precautions (EBP) during wound care for a resident with pressure ulcers. Despite signage at the resident's doorway indicating the need for gloves and precaution gowns during wound care, Nurse #3, Unit Manager #1, and a CNA all wore gloves but did not don precaution gowns as required by facility policy. Both Nurse #3 and Unit Manager #1 acknowledged that they should have worn gowns but did not do so during the observed wound dressing changes. Furthermore, proper hand hygiene protocols were not followed during the wound care procedure. Nurse #3 repeatedly failed to perform hand hygiene after removing gloves and before donning new gloves, as required by the facility's hand washing and non-sterile dressing change policies. This lapse was observed multiple times during the care of a resident with an unstageable pressure ulcer and a stage two pressure ulcer. Both Nurse #3 and Unit Manager #1 confirmed that hand hygiene should have been performed after each glove removal, but it was not consistently done.
Failure to Provide Effective Communication for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that staff communicated effectively with residents who have limited English proficiency, specifically for two residents whose primary languages were Korean and Vietnamese. Despite facility policy requiring the provision of interpreter services and communication aids, staff did not consistently utilize these resources. For the resident whose primary language was Korean, care plans indicated the need for communication boards, picture cards, and interpreter services, but these aids were not observed in the resident's room, and staff interactions did not involve attempts to communicate in the resident's language or through an interpreter. Staff were observed discussing the resident's needs among themselves without engaging the resident in a language they understood, and progress notes did not document the use of interpreter services during significant interactions. Similarly, for the resident whose primary language was Vietnamese, although a worn communication sheet was present, staff did not use interpreter services during critical events such as post-fall assessments. Care plans called for the use of communication devices and interpreter services, but staff interviews revealed a lack of knowledge on how to access these resources, and progress notes did not indicate that interpreters were used to communicate with the resident after falls. Staff were generally unaware of the resident's primary language and did not consistently attempt to communicate in a manner the resident could understand. Throughout the observations and interviews, it was evident that staff were either unaware of or did not follow the facility's policy regarding interpreter services for residents with limited English proficiency. The lack of effective communication tools and failure to use interpreter services resulted in residents not being able to express their needs or participate fully in their care, as required by facility policy and resident rights.
Failure to Offer and Facilitate Resident Choice of Alternate Meals
Penalty
Summary
The facility failed to provide three residents with the opportunity to exercise choice regarding their meals, specifically the option to select an alternate meal. Residents with varying cognitive statuses, including moderate cognitive impairment and intact cognition, reported that menus were not distributed and that they were not asked about their meal preferences. One resident stated that although an alternative meal was listed on the posted menu, staff consistently told them it was unavailable when requested. Another resident, who rarely left their room, was unaware of the menu's location and reported missing meals when the served food was not to their liking, as staff had previously told them it was too late to order an alternative. A third resident reported that staff refused to take their meal order and that attempts to call the kitchen for an alternative meal were unsuccessful due to unanswered calls. Staff interviews confirmed that menus were not handed out and were only sometimes posted by the elevators, which residents who remained in their rooms could not access. Certified Nurse Aides and the Unit Manager acknowledged that residents typically learned what was being served only when the meal was delivered, and that alternate meals were inconsistently provided, often depending on whether the kitchen could be reached by phone. The Food Services Director confirmed the lack of a policy regarding the offering of meal alternatives and was unaware of issues with the kitchen not answering calls. These actions and inactions resulted in residents not being consistently informed of meal options or able to exercise their right to choose alternate meals.
Failure to Consistently Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were consistently documented in the medical record for one resident. The facility's policy requires that all residents have the right to formulate an advance directive and that these directives be respected and documented according to state law and facility policy. For the resident in question, there were inconsistencies in the documentation of code status across various records. The Minimum Data Set (MDS) indicated the resident was a full code, while multiple progress notes from the medical doctor and nurse practitioner documented the resident as DNR/DNI. Hospital discharge paperwork also listed the resident as DNR/DNI, but the facility's care plan presumed full code status. Social services assessments noted the hospital code status as DNR/DNI and indicated that the facility would follow up to verify this status, but subsequent quarterly assessments showed that advanced directives had not been reviewed with the resident or responsible party. The resident's medical record also contained a blank MOLST form. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's code status. A nurse stated the resident was a full code and was unsure why the MD/NP documented otherwise. The DON confirmed that advanced directives should be discussed upon admission and quarterly, but could not explain the discrepancy in documentation. The social worker stated the resident was a full code due to having a guardian and admitted that she had not discussed advanced directives with the guardian. These actions and inactions led to the deficiency in ensuring proper documentation and communication of the resident's advance directives.
Failure to Use Interpreter Services for MDS Cognitive Assessments
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents who required interpreter services due to limited English proficiency. Both residents had primary languages other than English—Korean and Vietnamese—and their MDS documentation indicated a need for a translator to communicate. Despite this, the facility did not attempt to utilize interpreter services during the assessment process for cognition in Section C of the MDS. For the first resident, who had diagnoses including dementia, aphasia, and anxiety disorder, the MDS indicated that the Brief Interview for Mental Status (BIMS) was not completed because the resident was documented as rarely or never understood. Observations showed that the resident could not engage in an interview or respond to questions, and staff confirmed that an interpreter was needed but not used. The social worker responsible for completing Section C of the MDS stated that she did not use an interpreter, believing the resident would answer incorrectly even in their own language. Similarly, the second resident, with diagnoses of dementia and diabetes, was also documented as requiring a translator due to Vietnamese being their primary language. The BIMS was not completed, with the resident marked as rarely or never understood. Staff interviews revealed that the resident could not express needs in English, and staff were unaware of how to obtain interpreter services. The social worker again did not attempt to use an interpreter, citing cognitive confusion as the reason. These actions were contrary to both the RAI User's Manual and the facility's own interpreter services policy, which require assessments to be conducted in the resident's preferred language or with interpreter assistance.
Failure to Provide Required Assistance with Personal Hygiene and ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident, who was severely cognitively impaired and dependent on staff for hygiene, was observed multiple times with long, visibly dirty fingernails crusted with a brownish-black substance. Documentation and staff interviews confirmed that the resident did not refuse care, yet nail care was not provided as required by the care plan. Staff acknowledged that nail care should have been performed and that the resident typically does not refuse such care. Another resident, who was cognitively intact and required supervision or touching assistance with oral hygiene, reported not having a toothbrush and being unable to brush their teeth for an extended period. Observations confirmed the absence of a toothbrush and poor oral hygiene, with a thick yellowish-white substance on the resident's teeth. Documentation indicated that oral hygiene was marked as completed with set-up assistance or independently, rather than with the required supervision or touching assistance. Staff interviews revealed that the resident did not refuse care and that the required assistance and supplies were not provided. Facility policy required that mouth care and teeth brushing be provided with AM/PM care and as needed, and that staff follow the care plan and Kardex for each resident's specific needs. In both cases, the facility failed to follow these protocols, resulting in residents not receiving the necessary assistance with personal hygiene as outlined in their care plans.
Failure to Implement Specialist Recommendations for Pain Management and Therapy
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with chronic pain, cerebrovascular disease, and osteoarthritis. Despite an orthopedic specialist's recommendations for occupational therapy (OT) evaluation for new hand splints, use of Voltaren gel for pain management, and a referral to rheumatology, these interventions were not implemented. Review of the resident's clinical record, physician orders, and care plans showed no evidence that the specialist's recommendations were acted upon. The resident continued to experience regular hand pain and reported that promised splints were never provided. Interviews with facility staff revealed that recommendations from outside appointments are supposed to be communicated to the physician or nurse practitioner for implementation, but in this case, the recommendations were not relayed or documented in the electronic health record. The resident had not received OT services in the past six months, and the referral to rheumatology was only discovered much later when arranging a follow-up appointment. The nurse practitioner confirmed that the lack of documentation indicated the recommendations were not communicated to the care team, resulting in the resident not receiving the recommended treatments.
Failure to Implement Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were implemented according to physician orders for one resident with severe cognitive impairment and multiple comorbidities, including dementia and diabetes. The resident had two Stage III pressure injuries and was prescribed a low air loss mattress with settings to be adjusted according to the resident's current weight. Observations revealed that the air mattress was set at 350 lbs and later at 210 lbs, while the resident's documented weight was 144 lbs. Physician orders required the mattress setting to match the resident's weight and be checked every shift, but this was not consistently done. Additionally, the facility did not implement the wound physician's treatment recommendations as documented in the resident's medical record. The wound physician provided specific orders for wound care, including the application of alginate calcium, oil emulsion, skin substitute, and specific dressing changes at set intervals. However, the treatment administration records showed that these recommendations were not followed as ordered, with some treatments not being implemented or delayed. The medical record did not indicate that the wound physician's recommendations were addressed or carried out in a timely manner. Interviews with nursing staff and the DON confirmed that the wound physician's recommendations were to be followed and that attending physicians did not disagree with these orders. The process described by staff involved the wound physician alerting nursing staff to treatment changes, with nurses responsible for updating the clinical record. Despite this process, the required treatments were not consistently implemented, resulting in a failure to provide appropriate pressure ulcer care as ordered.
Failure to Implement OT Functional Maintenance Program After Discharge
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for a resident with hemiplegia and hemiparesis, who was discharged from OT with a functional maintenance program. The OT discharge summary specified that the resident should wear a right hand roll as tolerated and remove it for hygiene and care, with the goal of maintaining the current level of function. However, multiple observations by the surveyor showed the resident lying in bed with the right-hand fingers in a balled fist and without any orthotic device in place. Review of the medical record revealed that the physician's orders did not include the OT recommendations after discharge from therapy. Interviews with facility staff, including the unit manager, DON, and Director of Rehabilitation, confirmed that OT recommendations were supposed to be communicated to nursing staff and transcribed into physician's orders for ongoing implementation. The Director of Rehabilitation acknowledged that there was no record kept on the units of residents on a functional maintenance program and that the process relied on the discharging therapist training a nurse, who was then expected to add the necessary physician's order. This breakdown in communication and documentation resulted in the resident not receiving the prescribed functional maintenance program.
Failure to Investigate Fall and Maintain Elopement Prevention Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. For one resident with schizoaffective disorder and cerebral palsy, who had moderate cognitive impairment and required assistance with activities of daily living and transfers, the facility did not complete a post-fall evaluation or a full investigation after the resident sustained a fall resulting in a left ankle trimalleolar fracture. The medical record lacked documentation of a post-fall assessment, and the facility was unable to provide an incident or investigation report for the event. Interviews with staff and the DON confirmed that no investigation or evaluation was completed following the incident. For another resident with cerebral infarction, aphasia, dysphagia, depression, and moderate cognitive impairment, the facility failed to ensure the resident's wandergaurd bracelet was reapplied after it was noted to be off for multiple days. The resident was observed wandering the unit near the elevator on several occasions, and the wanderguard system was not triggered. Nursing progress notes repeatedly documented that the wandergaurd was off, but there was no evidence of attempts to replace it or implement alternative interventions, despite the resident being identified as an elopement risk and having a physician order for regular checks of the device. Staff interviews revealed a lack of consistent attempts to reapply the wandergaurd and no documentation of such efforts. The DON acknowledged that the resident was known to remove the device and that no alternative interventions were in place. The facility's failure to follow its own policies regarding incident investigation, post-fall evaluation, and elopement prevention led to deficiencies in providing a safe environment and adequate supervision for these residents.
Failure to Follow Dialysis Care Protocols and Communication Procedures
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents who required renal dialysis. For one resident with end-stage renal disease and a left arm AV fistula, nursing staff repeatedly documented obtaining blood pressures from the left arm, despite clear physician orders and care plan instructions prohibiting blood pressure measurements or blood draws from that arm. Documentation showed multiple instances where blood pressures were recorded from the left arm, and interviews with nursing staff and the Director of Nursing confirmed that this practice was not in accordance with the resident's care requirements. A second resident, also dependent on dialysis with a left arm AV fistula, had similar physician orders and care plan instructions to avoid blood pressure measurements and blood draws from the left arm. Despite these directives, the resident's records indicated that blood pressures were taken from the left arm 45 times after the order was implemented. Interviews with the unit manager and DON confirmed that staff should not have been taking blood pressures from the affected arm. Additionally, the facility failed to maintain an updated dialysis communication book for the second resident. The resident reported not receiving the communication book when leaving for dialysis, and documentation of communication between the facility and the dialysis center was inconsistent. The care plan did not reflect the resident's refusal to take the communication book, and there was a lack of consistent documentation regarding this refusal, as confirmed by staff interviews.
Unattended Unlocked Treatment Cart Containing Medications
Penalty
Summary
Surveyors observed that the facility failed to store drugs and biologicals in accordance with State and Federal laws, as well as the facility's own policy. On two separate occasions, the treatment cart on the sixth floor was found unlocked and unattended, with no staff in view. The surveyor was able to open the cart and found multiple prescription ointments and biologicals inside. Interviews with two nurses confirmed that the treatment cart should have been locked when unattended, but it was not. The Director of Nursing also confirmed that treatment carts are required to be locked when not attended by a nurse.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
Staff failed to maintain accurate medical records for three residents. For one resident with hemiplegia and severe cognitive impairment, staff documented in the Treatment Administration Record (TAR) that a left palm guard was applied during specific shifts, despite multiple observations by the surveyor and statements from the resident and unit manager indicating that the palm guard had not been worn for weeks and was missing. The physician's order required the palm guard to be applied during AM care and removed for hygiene and skin assessment every shift, but documentation did not reflect the actual care provided. For another resident with edema and intact cognition, the physician's order required bilateral lower extremity ace wraps to be applied daily in the morning and removed at bedtime. Review of the TAR showed that on several dates, staff documented unwrapping the ace wraps at night even though there was no documentation that the wraps had been applied in the morning. Interviews with the unit manager and DON confirmed that if the wraps were not applied in the morning, there would be nothing to remove at night, and documentation should accurately reflect the care provided. A third resident with schizoaffective disorder and cerebral palsy had physician's orders for Olanzapine, a psychotropic medication, with the diagnosis listed as "psych." The care plan referenced psychotropic drug use related to schizoaffective disorder, but the order itself did not specify an appropriate and accurate diagnosis. Interviews with the unit manager and DON confirmed that the diagnosis listed on the order was not sufficiently specific or accurate.
Failure to Provide Required Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal and influenza vaccinations to two residents out of a sample of five, as required by its own policies. One resident, admitted with dementia, had not received the influenza vaccine for the current season and was not offered it, despite having consented to both influenza and pneumococcal vaccinations. The resident's immunization history showed the last influenza vaccine was administered in the previous year and the last pneumococcal vaccine several years prior. The Minimum Data Set (MDS) assessment confirmed the resident had not received the influenza vaccine and was not offered it. Another resident, also admitted with dementia and psychosis, had not received the current influenza vaccination, with no reason documented, and was not up to date on pneumococcal vaccination nor offered it. The immunization record indicated the last influenza vaccine was given in the previous year, and there was no record of a pneumococcal vaccine. During interviews, the DON/Infection Preventionist confirmed that residents should be offered these vaccinations annually and upon eligibility but could not explain why these residents had not received or been offered the required vaccines.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccination to one resident who was eligible and had consented to receive the 2023/2024 COVID-19 vaccine. According to the facility's policy, all residents and staff should be offered the COVID-19 vaccine in a timely manner when supplies are available. The resident, admitted with a diagnosis of dementia, had last received a COVID-19 booster in December 2022 and was not up to date with the current vaccination as indicated in the Minimum Data Set Assessment. Documentation showed that the resident consented to the new vaccine, but there was no record of administration, and the Infection Preventionist was unable to explain why the vaccine was not given.
Failure to Provide Required SNF ABN Notices to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three out of three applicable residents when it was determined that they no longer qualified for Medicare Part A skilled services and had not exhausted their Medicare benefit days. The SNF ABN is necessary to inform residents or their representatives about the discontinuation of Medicare coverage for skilled services and to notify them of their potential financial responsibility if they choose to continue receiving those services. During the survey, the facility was unable to produce the requested SNF ABN forms for the affected residents. In an interview, the Regional MDS Nurse confirmed that the facility had not been providing ABN notices as required.
Failure to Maintain Adequate Staffing Levels
Penalty
Summary
The facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. The facility's assessment indicated a staffing plan that flexed based on census and acuity, with specific hours allocated for RNs, LPNs, and CNAs during weekdays and weekends. However, a review of the working schedules for the first quarter and the past 30 days revealed that the facility did not meet the appropriate staffing levels for 122 out of 122 days. During an interview, the Administrator acknowledged that the budgeted hours per patient per day (HPPD) for the facility census is 3.77 and admitted that staffing issues were limiting facility admissions. This deficiency was identified through interviews and record reviews, highlighting the facility's failure to maintain adequate staffing levels to meet the personal care needs of each resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. Resident #155, diagnosed with anxiety and PTSD, was administered Fluoxetine without a signed and dated psychotropic consent form. Both the nurse and social worker confirmed that the consent should have been obtained prior to administration. Similarly, Resident #84, diagnosed with major depressive disorder and PTSD, was given Mirtazapine without obtaining the necessary psychotropic consent. Interviews with the nurse, social worker, and Director of Nursing reiterated that the consent forms should have been secured before administering the medication. Resident #146, who had severe cognitive impairment and was receiving multiple psychotropic medications including Trazodone and Seroquel, also did not have a signed and dated psychotropic consent form in their medical record. The Director of Nursing and Nurse #4 both acknowledged that psychotropic medications require a signed consent prior to administration. The facility's policy, revised in January 2023, clearly states that consents should be obtained before administering psychotropic medications, yet this protocol was not followed for these three residents.
Failure to Secure Resident PHI
Penalty
Summary
The facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of three nursing units. The surveyor observed multiple instances where resident information was displayed on unattended nursing cart computers in the hallway and common areas of the cityside unit. The information displayed included residents' names, dates of birth, allergies, medications, vital signs, code status, and special instructions for treatment. This information was visible to any passerby, including other residents, while the nurses were in resident rooms administering medication. The observations were made at various times throughout the day, and in each instance, the nursing cart computer was left unattended with sensitive resident information visible. During an interview, the Director of Nursing confirmed that private resident information should not be exposed or visible to other residents while the nursing cart is unattended. The facility's policy on maintaining the security and confidentiality of PHI was not adhered to, leading to this deficiency.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment on three of four resident care units. During environmental rounds on the 3rd floor Arborside unit, multiple deficiencies were observed, including lifting paint, scuffed doors, missing paint, broken floor tiles, and strong odors in resident rooms and bathrooms. Additionally, the handrails throughout the unit were scuffed, and several rooms had marked-up walls, broken plaster, and missing or damaged furniture. The male and female resident bathrooms in the hallway also had significant issues, such as missing baseboards, strong odors, and peeling paint. On the 4th floor Bayside unit, similar issues were noted, including stained ceiling tiles, gouged bathroom walls, exposed plaster, and peeling floor molding. The hallway next to the nursing station and the dining room also had exposed plaster and stained ceiling tiles. These environmental deficiencies were observed during rounds and interviews with the Maintenance Director and the Director of Nurses (DON), who acknowledged the issues but indicated a lack of immediate plans to address them. On the 6th floor Dockside unit, the handrails across from a resident room and next to the nursing station were found to be loose and not completely secured to the wall. The Maintenance Director mentioned that her staff checks log books twice a day and prioritizes more urgent issues like broken call lights and toilets. However, she admitted that supplies need to be ordered and a plan made to address the multiple environmental issues in the building. The DON also acknowledged the environmental issues, particularly on the third floor, and admitted that the current state does not provide a homelike environment for the residents.
Failure to Report Altercation and Allegation of Abuse
Penalty
Summary
The facility failed to report an altercation between two residents and an allegation of abuse involving another resident. Specifically, the facility did not report a verbal altercation between two residents to the State Agency within the required two-hour timeframe. The incident involved Resident #68 and Resident #96, where the police were called to manage the situation. Despite the altercation being known to staff, it was not reported to the Director of Nursing or the State Agency as required by the facility's policy. Additionally, the facility failed to report an allegation of abuse involving Resident #19. The resident reported feeling humiliated by the Administrator, who publicly instructed the resident to wear a bra in the common areas, causing embarrassment. The incident was witnessed by staff members who did not report it due to fear of retaliation. The Director of Nursing was not informed of the incident until it was brought to her attention by the surveyor. The facility's policy on abuse prevention and reporting was not followed in both cases. Staff failed to report the incidents immediately, and the required notifications to the State Agency were not made. The facility's failure to adhere to its own policies and state regulations resulted in deficiencies in handling and reporting suspected abuse and altercations among residents.
Failure to Investigate Altercation and Allegation of Abuse
Penalty
Summary
The facility failed to investigate an altercation between two residents and an allegation of abuse involving another resident. Resident #68, with a diagnosis of bipolar disorder and intact cognition, reported a verbal altercation with Resident #96, who also has bipolar disorder but with moderate cognitive impairment. The incident, which occurred on 11/23/23, involved the police being called. Despite staff being aware of the altercation, no investigation was initiated, and the Director of Nurses was not informed immediately as required by the facility's policy. The Director of Nurses confirmed that an investigation should have been conducted but could not locate any completed investigation documentation for the incident. In another incident, Resident #19, who is cognitively intact, reported feeling humiliated by the Administrator who publicly instructed the resident to wear a bra in the common areas. Multiple CNAs corroborated the resident's account, stating that the Administrator yelled at staff to ensure the resident wore a bra, which was overheard by others. The CNAs did not report the incident due to fear of retaliation. The Director of Nursing and Corporate Nurse confirmed that the resident has the right to choose their attire and that the Administrator's actions were inappropriate. The incident was not reported or investigated as required by the facility's policy. Both incidents highlight a failure to follow the facility's abuse policy, which mandates immediate reporting and investigation of any allegations or incidents involving abuse, neglect, or mistreatment. The lack of timely reporting and investigation in both cases indicates a significant lapse in adhering to established protocols designed to protect residents' rights and ensure their safety and dignity.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to multiple deficiencies. Resident #59's preferred language was incorrectly coded as Italian, despite the resident only speaking Spanish. This error was confirmed through interviews with the resident, the Activities Director, and the Social Worker, as well as an admission by the MDS Nurse who acknowledged the mistake. Resident #144's MDS was inaccurately coded to indicate hospice services before the resident was actually admitted to hospice care, which was confirmed by the MDS Nurse and a review of the resident's records and physician's orders. Resident #98's MDS assessment failed to document a contracture in the resident's left hand, which was observed by the surveyor and confirmed by the Director of Rehab and the Director of Nurses. Similarly, Resident #103's MDS assessment did not indicate a contracture in the right hand, despite observations and confirmations from the Director of Rehab and nursing staff. Additionally, Resident #103's MDS failed to document the administration of an antipsychotic medication, even though the resident had a physician's order for Olanzapine and received it daily as confirmed by the Medication Administration Record and the Director of Nurses. These inaccuracies in the MDS assessments highlight a failure in the facility's processes for accurately documenting resident information. The errors were identified through a combination of observations, interviews, and record reviews, indicating a need for improved accuracy and verification in the MDS coding process.
Failure to Implement and Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure resident-centered care plans were implemented and/or developed for seven residents. For Resident #60, the facility did not implement the right-hand grip splint as ordered. Despite physician orders and care plans indicating the need for the splint, the resident was observed multiple times without it. Interviews with staff revealed that the splint had not been seen or used for a long time, indicating a failure to follow the care plan and physician orders. For Resident #92, the facility failed to provide supervision during meals and did not implement the use of booties for the resident's feet while in bed. The resident, who has severe cognitive impairments, was observed eating without supervision on multiple occasions, contrary to the care plan. Additionally, the resident was observed without booties on their feet, despite care plans and staff interviews confirming the necessity of these interventions to prevent skin damage. Other deficiencies included the failure to implement fall prevention measures for Resident #5, develop a pain management care plan for Resident #142, and address a contracture for Resident #103. The facility also did not create personalized care plans for alcohol abuse for Residents #96 and #85, and failed to develop a communication care plan for Resident #85, who speaks Spanish and requires interpreter services. These failures indicate a significant lapse in the development and implementation of individualized care plans for residents with specific needs.
Failure to Meet Professional Standards of Nursing Practice
Penalty
Summary
The facility failed to meet professional standards of nursing practice for four residents. For Resident #107, the facility did not regularly notify the Nurse Practitioner, Psychiatric Nurse, or [NAME] Monitor after the resident refused to take prescribed antipsychotic medication on multiple occasions. Despite the resident's history of dementia with behavioral disturbances and a treatment plan requiring notification of refusals, the medical record showed no evidence of such notifications. Interviews with staff confirmed that the expected notifications were not made, which could have allowed for timely intervention and adjustment of the treatment plan. For Resident #101, the facility did not follow the physician's order to contact the medical doctor when the resident's blood sugar levels fell below a specified threshold. The resident, who has a diagnosis of type 2 diabetes mellitus, had a blood sugar reading of 62 mg/dL, but there was no documentation that the physician was notified as required. Interviews with the Director of Nursing and a nurse confirmed that the physician's order was not followed, and the necessary documentation was missing from the resident's medical record. Resident #142 did not receive an occupational therapy evaluation as ordered by the physician for bilateral hand arthritis with pain, tenderness, and stiffness. The order for the evaluation was not communicated to the rehab department, and the most recent evaluation available was from several months prior. Interviews with the Director of Rehab and a Unit Manager confirmed that the order was not executed. Additionally, for Resident #38, the facility failed to address a malfunctioning suprapubic catheter according to professional standards. When the catheter became blocked, staff attempted to resolve the issue improperly by cutting and tying the catheter, rather than stopping and notifying the physician. Interviews with the Director of Nursing, Unit Managers, and the nurse involved confirmed that the correct procedure was not followed, leading to the resident being sent to the hospital for evaluation.
Failure to Address Nutrition and Hydration Needs
Penalty
Summary
The facility failed to address the nutrition and hydration status of three residents, leading to significant deficiencies. Resident #74 experienced a significant weight gain of 7.21% over 23 days, which was not identified or addressed in a timely manner due to a lapse in Registered Dietitian (RD) coverage. The resident's care plan and nutritional assessments failed to capture this weight gain until 72 days later, indicating a lack of proper monitoring and intervention during the period when no RD was available in the facility. Resident #26 had a significant weight loss of 15.18% over 194 days, which was not identified or addressed due to the absence of regular weight monitoring. The resident's care plan indicated the need for regular weighing and monitoring, but there was no documentation of weights being taken from August 18, 2023, to February 28, 2024. The Mini Nutritional Assessment did not capture the significant weight loss because it only looked back three months, highlighting a gap in the facility's monitoring process. Resident #38 was not provided with sufficient fluids to maintain proper hydration. Despite care plan interventions to offer fluids between meals and encourage fluid intake, the resident's water pitcher was consistently found empty and out of reach. The resident reported having to beg for water and not being offered fluids regularly, leading to a risk of dehydration. Observations confirmed that staff did not offer fluids to the resident between meals, and the resident's fluid intake from meal trays alone was insufficient to meet their estimated daily needs.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for three out of five CNAs and three out of four licensed nurses. Additionally, the facility did not ensure that licensed nurses received competencies regarding suprapubic catheter care before caring for a resident with a suprapubic catheter. A resident with a chronic suprapubic catheter experienced a blockage in the catheter. The nursing staff, including two unit managers and a nurse, attempted to address the issue but were unable to deflate the balloon of the catheter. One of the nurses cut the catheter and tied it into a knot, which was not proper practice. The resident was subsequently sent to the hospital, where it was confirmed that the catheter had been improperly handled. Interviews with the nursing staff involved revealed that they had not received the necessary education or competency training regarding catheter care before the incident. The facility was unable to provide evidence that the staff had completed the required competencies for catheter care, highlighting a significant gap in the training and competency evaluation process.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for three of six sampled CNAs. During a review of six CNA employee records, it was noted that three CNAs did not receive their annual performance reviews. In an interview with the Corporate Staff Development Coordinator (SDC), it was confirmed that performance reviews should be completed annually around the employees' anniversary hire date and should be kept in their files.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and administered according to professional principles and guidelines. Specifically, a resident with moderate cognitive impairment was found with an unsupervised medication at their bedside. The medication, identified as Ibuprofen 400 MG, was not documented in the resident's Medication Administration Record (MAR), and there was no consent form allowing the resident to self-administer medications. The nurse on duty confirmed that the medication should not have been left at the bedside and should have been documented if administered. Additionally, the facility did not properly label and store medications on two of four sampled medication carts and in two of two sampled medication rooms. Observations included inhalers and vials that were either undated or not stored according to manufacturer guidelines. For instance, an Anuity Elipta inhaler was found with an open date exceeding the manufacturer's discard timeframe, and an Ativan box was found unlocked in the fridge. Nurses and unit managers confirmed that these medications should have been labeled with open dates and stored appropriately. The Director of Nursing (DON) acknowledged that medications should be stored in an orderly and clean manner, with proper labeling and storage as per guidelines. The DON also confirmed that medication carts and rooms should be clean, and unopened insulin vials should be refrigerated. The facility's failure to adhere to these standards was evident in the observations made during the survey.
Food Safety Violation in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the food line in the kitchen, a cook contaminated saran wrap by holding it with her chin and resting it over her apron. The contaminated saran wrap was then used to cover a pan of food on the steam table. This action was repeated a total of four times during the preparation of the tray line for the lunch meal. Interviews with the Food Service Director and another dietary staff member confirmed that saran wrap contaminated by the chin and apron should not be applied onto food.
Failure to Offer and Educate on COVID-19 Vaccine
Penalty
Summary
The facility failed to offer or provide education for the 2023-2024 COVID-19 vaccine to five residents. The facility's policy requires that residents, visitors, and staff be offered the COVID-19 vaccine and be educated on its benefits and potential side effects. However, the medical records of the five residents reviewed did not indicate that they had been offered the vaccine, educated on it, or had refused it. Additionally, the records did not show any allergies to the COVID-19 vaccine, and some residents had signed consents for the vaccine dated after the surveyor brought the issue to the facility's attention. Resident #108's family member reported that they had requested the vaccine multiple times, but the facility did not provide it, citing the need to open a new vial. Resident #83 stated that they had not been offered or educated on the vaccine. The medical records of Residents #125, #82, and #117 also lacked documentation of vaccine education, offering, or refusal. The Regional Infection Control Nurse confirmed that the facility had not documented the offering or education of the vaccine and had not yet ordered the vaccines for administration. The Regional Infection Control Nurse and the Assistant Director of Nursing (ADON) acknowledged the oversight and mentioned that they had started obtaining consents for the COVID-19 vaccine after the surveyor's concern was raised. The ADON had begun the process of obtaining consents the previous week but had not yet ordered the vaccines for administration. The facility's failure to follow its policy and document the offering and education of the COVID-19 vaccine led to the deficiency identified by the surveyors.
Failure to Complete Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that at least 12 hours of in-service training was completed for three of five Certified Nurse Aides (CNAs) reviewed. During the review of employee education files, it was noted that three CNAs did not receive the required 12 hours of in-service education within 12 months. The Corporate Administrator confirmed that the expectation is for all education to be completed yearly to ensure all nursing staff are competent in the care they provide to the residents.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, for residents who were dependent on staff for assistance with meals, staff were observed standing over the residents while providing assistance on the third floor unit. The facility's policy on dignity, dated 10/22, indicated that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. However, on 4/17/24, a surveyor observed multiple instances where Certified Nurses Assistants (CNAs) were standing, not at eye level, while assisting residents with their meals. During an interview on 4/19/24, the Director of Nurses (DON) confirmed that CNAs should never stand while feeding a resident and should be seated at eye level with the resident while assisting them with their meal.
Improper Room Change Notification and Handling
Penalty
Summary
The facility failed to notify a resident of a room change, including the reason for the change, for one resident out of a total sample of 39 residents. Specifically, the facility did not provide a written notice explaining the reason for a room change for Resident #108, resulting in the resident being moved to a new room against their wishes. The facility's policy requires that residents be informed both verbally and in writing about room changes, including the reasons for the change, and that such information be documented in the resident's medical record. However, this procedure was not followed in the case of Resident #108, who was moved abruptly without proper notice or consent, and the room change form was completed after the move, not prior as required by policy. Resident #108, who had diagnoses including cerebral infarction, osteomyelitis, and insomnia, was admitted to the facility in January 2023. The resident had a Brief Interview for Mental Status score indicating intact cognition. The resident reported that the room change occurred without any warning and against their wishes, and that their belongings were hastily packed into bags and moved to a new room within five minutes. The resident and their family member expressed dissatisfaction with the abrupt move and the condition of the new room, which was not move-in ready. The resident's belongings remained unpacked for two days, and the new room lacked essential furniture, causing further distress. Interviews with facility staff, including the Social Worker, DON, and Maintenance Director, confirmed that the room change was handled improperly. The Social Worker and DON stated that the resident should have been allowed to refuse the room change and that the new room should have been prepared in advance. The Administrator acknowledged that the process was not appropriate and that residents should receive reasonable notice for room changes. The improper handling of the room change led to significant distress for Resident #108, who reported feeling more depressed due to the new roommate and the overall experience.
Failure to Provide Timely Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident's request to access personal funds for less than $100.00 ($50.00 for Medicaid residents) was honored within the same day. Specifically, the facility required 48 hours notice for a resident to gain access to $25.00 of personal funds. Resident #6, who was admitted to the facility in February 2007 with diagnoses including adult failure to thrive, was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident expressed frustration during an interview, stating that he/she had to wait up to a week to access $25.00 from personal funds, which hindered his/her ability to make spontaneous purchases. The Business Office Assistant confirmed that any request for $25.00 or more required 48 hours notice due to the process of requesting and cashing a check. The Administrator acknowledged that all residents should have access to a realistic amount of their funds daily and that Resident #6 should have been able to get $25.00 the same day. This deficiency highlights the facility's failure to honor the resident's right to manage his/her financial affairs promptly.
Resident Humiliated by Administrator's Inappropriate Comments
Penalty
Summary
The facility staff failed to ensure that a resident was free from verbal and mental abuse. Specifically, the Administrator told a resident to wear a bra in a common area, which resulted in mental anguish and psychological distress for the resident. The resident, who was cognitively intact, reported feeling humiliated and uncomfortable due to the Administrator's actions and comments made in a public setting. The incident occurred when the Administrator approached the resident in the day room and instructed them to return to their room to put on a bra, stating that the resident was dressed inappropriately. Despite the resident expressing discomfort with wearing a bra, the Administrator insisted and later yelled at staff members to ensure the resident wore a bra in common areas. Multiple staff members confirmed the Administrator's inappropriate and public handling of the situation, which embarrassed the resident. Interviews with various staff members, including CNAs and the Activities Director, corroborated the resident's account of the incident. The staff members acknowledged that the Administrator's actions were inappropriate and that the resident's choice not to wear a bra should have been respected. The Director of Nursing and Corporate Nurse were not initially aware of the incident, and the facility's abuse reporting procedures were not followed, as staff feared retaliation for reporting the Administrator's behavior.
Failure to Implement Abuse Policy and Investigate Allegations
Penalty
Summary
The facility failed to ensure staff implemented their abuse policy for two residents. Specifically, the facility did not ensure that the accused staff member was not employed in the building while an abuse investigation was still pending for one resident. Additionally, the facility failed to identify, report, and investigate another resident's abuse allegation. These deficiencies were observed through interviews, record reviews, and direct observations by surveyors. One resident, who was admitted with diagnoses including cerebral infarction, osteomyelitis, and insomnia, reported feeling retaliated against after making a complaint about a nurse. The resident was abruptly moved to a different room with little notice, and their belongings were packed in trash bags, causing distress and fear of further retaliation. Despite the ongoing investigation, the accused nurse continued to work in the facility, which was against the facility's policy. Another resident, admitted with diagnoses including asthma and heart failure, reported feeling humiliated by the Administrator, who publicly demanded that the resident wear a bra. This incident was witnessed by other staff members, who did not report it due to fear of retaliation. The facility's Director of Nursing and governing body were unaware of this allegation until it was reported by the surveyor, indicating a failure in the facility's abuse reporting and investigation processes.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely written notifications of transfer or discharge to the hospital for two residents, as required by policy. Resident #64, who was admitted with diagnoses including diabetes mellitus and severe obesity, was transferred to the hospital on two occasions. However, there were no progress notes or filed copies of written notices of transfer for these dates in the resident's electronic medical record. The Social Worker confirmed that if the notices are not filed in the chart, they were not provided to the resident, indicating a lapse in the facility's procedure for notifying residents and the ombudsman of transfers or discharges. Similarly, Resident #118, admitted with diagnoses including Type 2 diabetes mellitus, depression, and anxiety disorder, was transferred to the hospital but did not receive any paperwork prior to the discharge. The clinical record lacked evidence of a transfer/discharge notice being provided. Interviews with the Social Worker and the Director of Nursing revealed that the responsibility for completing and providing the discharge/transfer notice lies with the nursing staff, but this procedure was not followed, resulting in the deficiency.
Failure to Complete SCSA MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment for a resident who elected to receive hospice care services. The resident, admitted in July 2023 with diagnoses including dementia and adult failure to thrive, had a most recent MDS assessment dated March 1, 2024, indicating severe cognitive impairment. Hospice services were initiated for the resident on March 6, 2024, as documented in the physician's orders and nursing progress notes. However, the required SCSA MDS assessment was not completed within the 14-day timeframe following the significant change in status. This oversight was confirmed during an interview with the MDS Nurse on April 17, 2024, who acknowledged that the assessment should have been completed but was not done.
Failure to Revise Behavior Care Plan
Penalty
Summary
The facility failed to revise and update the behavior care plan for a resident diagnosed with Dementia with behavioral disturbance and a history of falls. The resident, who is rarely understood, prefers to sit in a pitch-black room with the curtains drawn and becomes very upset if staff turn on the lights or draw the curtains. This specific behavior was not included in the resident's behavior care plan, which was last revised on 2/8/24. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyor. During interviews, a CNA, a nurse, and a social worker all confirmed that the resident likes to sit in a pitch-black room and gets upset when the lights are turned on or the curtains are drawn. The nurse mentioned that the resident is currently on antipsychotic medications and has a history of falls, indicating that there should be a care plan developed with interventions on how to manage the resident's specific behavior. The social worker acknowledged the need to revise and update the behavior care plan to include this specific behavior and personalized interventions.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs), specifically showers, for a resident with moderate cognitive impairments. The resident, who has diagnoses including Alzheimer's disease, bipolar disorder, obsessive-compulsive disorder, chronic respiratory failure with hypoxia, and repeated falls, reported not receiving a shower in two weeks despite being scheduled for showers on Mondays and Thursdays. The resident's most recent Minimum Data Set (MDS) assessment indicated that the resident requires supervision/touch assistance of one staff member for bathing. The facility's policy states that residents unable to carry out ADLs independently will receive necessary services to maintain good hygiene, but this was not adhered to in this case. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care did not offer the resident a shower on the scheduled days and did not document any refusal of care. The Unit Manager and Director of Nursing (DON) confirmed that refusals should be documented in the nursing notes and ADL flow sheet, but there was no indication in the resident's medical record that the resident had refused care. This lack of documentation and failure to provide scheduled showers led to the deficiency noted in the report.
Failure to Follow Physician's Orders for Dressing Change
Penalty
Summary
The facility failed to ensure that Resident #115 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not complete a dressing change for Resident #115 as per the physician's orders. The resident, who was admitted in January 2024 with diagnoses including dementia, edema, chronic pain, and lack of coordination, had a dressing on their left hand that was observed to have red, dry stains consistent with blood on two consecutive days, 4/16/24 and 4/17/24. The dressing was dated 4/15/24, indicating it had not been changed daily as required by the physician's order dated 4/15/24, which specified daily dressing changes with normal saline, bacitracin, and a dry protective dressing, along with monitoring for signs of infection for 14 days. The review of the April 2024 Treatment Administration Record (TAR) indicated that the dressing was supposedly changed on 4/16/24, but observations and interviews contradicted this. Nurse #6 confirmed that the dressing was not changed on 4/16/24, and the Director of Nurses (DON) stated that the expectation was for the dressing to be changed daily. The DON also mentioned that any refusal of care by the resident should be documented in the TAR and nurse's progress notes, which was not done in this case. The failure to change the dressing as ordered and the lack of proper documentation led to the deficiency noted in the report.
Failure to Implement Proper Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the prevention and treatment of pressure ulcers for a resident with severe cognitive impairments and a stage 4 pressure ulcer. Specifically, the air mattress for the resident was consistently set to 90 lbs, despite physician orders and care plan instructions to set the mattress according to the resident's current weight, which was 128.6 lbs as of the most recent medical record. This discrepancy was observed over multiple days by the surveyor. Interviews with the nursing staff and the Director of Nurses confirmed that the air mattress should have been set according to the resident's weight as per the physician's orders. The failure to adjust the air mattress setting appropriately was identified as a deficiency in the care provided to the resident, who was at high risk for developing additional pressure ulcers due to their existing stage 4 pressure ulcer and severe cognitive impairments.
Failure to Adhere to Smoking and Fall Prevention Policies
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards, specifically in the storage of smoking materials and the investigation and assessment of a resident after a fall. Resident #85, who has a traumatic brain injury and moderate cognitive impairment, was observed multiple times with a pack of cigarettes in their bedside drawer, contrary to the facility's smoking policy which mandates that smoking materials be held by nursing staff. Despite the policy and the resident's signed smoking rules and safety agreement, the resident was able to access and retain cigarettes in their room, posing a safety hazard. Staff interviews confirmed that smoking materials should be locked away by staff for safety purposes, but this was not adhered to in the case of Resident #85. Resident #74, who has epilepsy, insomnia, and alcoholic cirrhosis, experienced a fall that resulted in hospitalization. The resident was found on the floor next to their bed with a bottle of vodka. Despite the facility's fall prevention and management policy, which requires a fall risk assessment and thorough documentation post-fall, no fall assessment was completed for Resident #74. Additionally, the incident report for the fall was incomplete and inaccurately indicated that the resident did not go to the hospital. Interviews with staff revealed that the resident was inebriated at the time of the fall and that an investigation and fall assessment should have been conducted but were not. These deficiencies highlight lapses in the facility's adherence to its own policies regarding smoking materials and fall prevention. The failure to store smoking materials safely and to properly investigate and assess a resident after a fall resulted in potential safety hazards for the residents involved. Staff interviews corroborated the observations and indicated a lack of compliance with established safety protocols.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop and implement trauma-informed care plans for two residents diagnosed with post-traumatic stress disorder (PTSD). Resident #155, admitted in March 2024, had diagnoses including anxiety and PTSD. Despite a psychiatric evaluation confirming the PTSD diagnosis and a physician's order for Fluoxetine HCI to manage PTSD, the resident's care plan did not include a personalized PTSD care plan. The Social Worker confirmed that a personalized PTSD care plan should have been developed in addition to the mood care plan. Similarly, Resident #84, admitted in February 2024, had diagnoses including major depressive disorder and PTSD. A psychiatric evaluation also confirmed the PTSD diagnosis. However, the resident's care plan lacked a personalized PTSD care plan. The Social Worker acknowledged that a personalized PTSD care plan should have been created in addition to the mood care plan. The facility's failure to develop these care plans is a direct violation of their trauma-informed care policy, which mandates individualized interventions for residents with a history of trauma.
Failure to Re-evaluate Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for a resident. The facility's policy requires that PRN orders for psychotropic medications must have a stop date and be re-evaluated by a physician every 14 days to continue. However, the review of Resident #40's physician orders indicated that the Lorazepam order did not have an end date, and there was no documentation of re-evaluation by a physician after 14 days of use. Resident #40, who was admitted with diagnoses including pneumonia, anxiety disorder, and depression, had a BIMS score indicating cognitive intactness, yet the facility did not comply with its own policy regarding the administration of psychotropic medications. During an interview, the Director of Nursing confirmed that PRN psychotropic medication orders need a stop date and must be re-evaluated every 14 days by a physician. The failure to follow this policy was evident in the case of Resident #40, where the Lorazepam order lacked an end date and was not re-evaluated as required. This oversight indicates a lapse in the facility's adherence to its procedures for the appropriate use, evaluation, and monitoring of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control practices for Resident #136, who was admitted with diagnoses including dementia and a stage 4 pressure ulcer. Despite the facility's policy on Enhanced Barrier Precautions (EBP) requiring such measures for residents with wounds or indwelling medical devices, no EBP was implemented for Resident #136. Observations over three days revealed no personal protective equipment (PPE) in or outside the resident's room, and no indication that the resident was on EBP. Interviews with nursing staff and the Director of Nurses (DON) confirmed a lack of awareness and education regarding EBP. Nurses and CNAs admitted they had not received training on EBP and were unaware that PPE was needed for residents with chronic wounds or medical devices. The DON acknowledged the requirement for EBP but confirmed it was not in place for Resident #136, despite the presence of multiple residents with similar needs in the facility.
Failure to Offer Influenza Vaccinations per CDC Recommendations and Facility Policy
Penalty
Summary
The facility failed to offer influenza vaccinations per CDC recommendations and facility policy for two residents. The facility's policy, revised in February 2023, mandates that residents should be offered vaccines unless medically contraindicated or already vaccinated. Additionally, the policy requires documentation of vaccine education, administration details, and any refusals in the resident's medical record. However, the facility did not adhere to these guidelines for two residents. Resident #83, admitted in December 2021 with chronic obstructive pulmonary disease, reported not being offered or educated about the influenza vaccine. Resident #83's medical record showed no documentation of receiving, refusing, or being educated about the vaccine since October 2021. Similarly, Resident #125, admitted in January 2023 with heart failure, had no documentation of receiving, refusing, or being educated about the influenza vaccine since October 2022. During interviews, it was revealed that the facility had not been offering the influenza vaccine due to logistical issues, such as not having enough residents to use a new vaccine vial. The Regional Infection Control Nurse confirmed that the facility should have started obtaining influenza vaccine consents in August 2023 and offering the vaccine throughout the influenza season. The nurse also confirmed that all residents are eligible for the influenza vaccine unless they have a listed allergy. The lack of documentation and offering of the vaccine to Residents #83 and #125 indicates a failure to comply with both CDC recommendations and the facility's own vaccination policy.
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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