Jesmond Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Nahant, Massachusetts.
- Location
- 271 Nahant Road, Nahant, Massachusetts 01908
- CMS Provider Number
- 225471
- Inspections on file
- 19
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Jesmond Nursing Home during CMS and state inspections, most recent first.
A resident with Alzheimer's and severe cognitive impairment was hospitalized for dehydration and hypernatremia after the LTC facility failed to notify the physician of a significant decline in food and fluid intake. Despite a care plan to monitor dehydration signs, the resident's condition worsened over several days without timely communication to the medical team, leading to hospitalization.
The facility failed to address the nutrition and hydration needs of two residents, leading to severe dehydration in one and significant weight fluctuations in another. A resident with Alzheimer's and malnutrition was hospitalized due to dehydration after staff failed to communicate intake issues. Another resident with CHF experienced significant weight changes without intervention or documentation from the dietitian. Staff interviews revealed communication and documentation lapses regarding the residents' nutritional status.
The facility failed to provide timely incontinence care for a resident with severe cognitive impairment, leaving them unattended for extended periods without checks. Additionally, three residents requiring supervision during meals were left unsupervised, and a resident did not receive scheduled showers due to unreported refusals. Staff misinterpretation of care plans contributed to these deficiencies.
A resident with severe cognitive impairment was transferred to the hospital against their advanced directives, which included DNR, DNI, and DNH orders. After the passing of the resident's spouse, who was the health care proxy, the facility did not update the guardianship or seek guidance on the resident's directives. An attorney advised changing the resident's code status to full code, leading to the hospital transfer, despite the resident's documented wishes and the nurse practitioner's concerns.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and schizophrenia, did not receive timely incontinence care as per their care plan. Observations showed the resident was left in a Broda chair for extended periods without being checked for incontinence, despite being at risk for pressure ulcers. Staff interviews confirmed the neglect, as the care plan requiring checks every two hours was not followed.
A facility failed to conduct a restraint assessment before adding a bolster pillow to a resident's bed. The resident, with moderate cognitive impairment, was observed with the pillow, which was not documented in the bed safety assessments or physician's orders. Staff interviews confirmed the lack of assessment, contrary to facility policy requiring such evaluations before using restraints or safety devices.
The facility failed to follow care plans and physician orders for three residents, leading to deficiencies in care. A resident with severe cognitive impairment did not receive the prescribed air mattress, while two other residents, one cognitively intact and one with severe impairment, did not have their heels offloaded as required. Staff were unaware of these requirements, and there was no documentation of resident refusal.
A facility failed to document blood pressure parameters before administering metoprolol to a resident with cardiomyopathy, as per physician's orders. The nurse claimed the night shift was responsible for taking the blood pressure, but no documentation was found in the MAR. The DON confirmed that orders should be followed and documented.
The facility failed to conduct weekly skin assessments for two high-risk residents, as required by their care plans. One resident, with conditions like dementia and Parkinson's, had a four-week gap in skin checks. Another resident, with congestive heart failure and diabetes, missed assessments on two occasions. Staff interviews confirmed the oversight in following physician orders.
A resident with a right hand contracture was not provided with a prescribed hand splint, as observed during a survey. The resident, with a history of cerebral infarction and hemiparesis, was found without the splint on two occasions, despite a physician's order for its use to prevent further contracture and skin breakdown. Interviews with staff revealed a lack of adherence to the care plan, and the Director of Nursing acknowledged the oversight.
A resident with respiratory and heart failure, who required substantial assistance for mobility, reported a fall that was not investigated by the facility. Despite a referral for rehabilitation services indicating the fall, the facility failed to document the incident in nursing notes or conduct an investigation, as confirmed by interviews with the DOR and Corporate Nurse.
The facility failed to manage medications properly, with issues including undated opened medications, expired medications not removed, and unsecured medication carts left unattended. Nurses acknowledged their responsibilities, but practices were inconsistent, as confirmed by the DON.
A resident with moderate cognitive impairment and specific dietary needs was not provided with the correct minced texture diet as ordered by the physician. Observations showed the resident receiving whole pieces of chicken and sausage, contrary to the minced diet requirement. Staff interviews revealed miscommunication and confusion about the resident's dietary needs, leading to the deficiency.
A facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and diabetes. The resident's physician orders required an air mattress to be checked every shift, but observations showed a different mattress was used. The Medication Treatment Record inaccurately documented the presence of the air mattress, and a Unit Manager confirmed the resident had not had an air mattress for at least two weeks.
A facility failed to implement its infection control program by not ensuring the proper disinfection of blood glucose meters. A nurse was observed obtaining a resident's blood sugar and then placing the contaminated glucometer in a carrier case without disinfecting it, contrary to the facility's policy. The nurse later acknowledged the requirement to sanitize the meter after each use.
Failure to Notify Physician of Nutritional Status Change
Penalty
Summary
The facility failed to notify the physician of a change in nutritional status for a resident, resulting in hospitalization for dehydration and hypernatremia. The resident, who was admitted with Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia, was dependent on staff for all daily care tasks and had severe cognitive impairment. Despite a care plan in place to monitor and report signs of dehydration, the resident experienced a significant decline in food and fluid intake over several days, which was not communicated to the physician, nurse practitioner, or dietitian in a timely manner. Observations revealed that the resident had not consumed meals for most of the days leading up to the hospitalization, and the clinical record lacked documentation of any notification to the medical team about this change. Interviews with staff indicated a breakdown in communication, as the nurse who noticed the change in intake did not ensure the information was passed on to the appropriate personnel. The unit manager, who returned from vacation, observed the resident's condition but delayed contacting the nurse practitioner, expecting to discuss the situation during a scheduled visit. The nurse practitioner confirmed that she was not informed of the resident's poor intake until the day of hospitalization.
Failure to Address Nutrition and Hydration Needs
Penalty
Summary
The facility failed to adequately address the nutrition and hydration needs of two residents, leading to significant health issues. Resident #24, who was admitted with Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia, was found to have severe dehydration and hypernatremia. Despite being dependent on staff for all daily care tasks, the resident's lack of food and fluid intake over several days was not communicated to the nurse practitioner or dietitian, resulting in a critical condition that required hospitalization. Resident #32, diagnosed with congestive heart failure, moderate protein-calorie malnutrition, and type 2 diabetes mellitus, experienced significant weight fluctuations that were not addressed by the registered dietitian. The resident's weight log showed multiple instances of significant weight gain and loss, yet there was no documentation of nutritional assessments or interventions. The dietitian admitted to not documenting or intervening for significant weight gains, even for residents with conditions like CHF, and there was no nutritional care plan in place for this resident. Interviews with facility staff revealed a lack of communication and documentation regarding the residents' nutritional and hydration status. Nurse #1 acknowledged failing to notify the nurse practitioner about Resident #24's change in intake, while the dietitian and unit manager were unaware of the severity of the situation. Similarly, the registered dietitian did not document or address Resident #32's weight changes, and the director of nursing and unit manager could not explain the absence of documentation or a care plan for the resident's nutritional needs.
Deficiencies in ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. Observations revealed that the resident was left unattended in a Broda chair for extended periods without being checked for incontinence, despite having a care plan that required checks every two hours. Staff interviews confirmed that the resident was not provided incontinence care for over three hours, and it was only after the surveyor's intervention that the resident received the necessary care. The facility also failed to provide adequate supervision during meals for three residents who required supervision or assistance with eating. Observations showed that these residents were left unsupervised while eating, contrary to their care plans which indicated the need for continuous supervision. Staff interviews revealed a misunderstanding of the term "continuous supervision," with some staff interpreting it as allowing them to leave and return to check on residents, rather than providing constant oversight. Additionally, the facility did not adhere to the scheduled shower routine for a resident who required substantial assistance with bathing. The resident reported not receiving a shower for 3-4 weeks, and staff interviews confirmed that a refusal of care was not reported to the nurse, leading to a lapse in the resident's hygiene care. This failure to follow the care plan and report refusals contributed to the deficiency in providing necessary personal care.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to adhere to the advanced directives of a resident, resulting in the resident being transferred to the hospital against their documented wishes. Resident #24, who was admitted with severe cognitive impairment and dependent on staff for daily care, had clear advanced directives documented, including a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) order. These directives were established by the resident's spouse, who was the health care proxy and guardian, as indicated in the Medical Orders for Life-Sustaining Treatment (MOLST) form. After the passing of the resident's spouse, the facility did not seek guidance on the resident's advanced directives and continued to maintain the physician order of DNR/DNI/DNH. However, when the resident's condition declined, the facility consulted an attorney who advised changing the resident's code status to full code, leading to the resident being sent to the hospital. This decision was made despite the resident's documented wishes and the nurse practitioner's belief that the MOLST form should remain valid. The facility's social worker and nurse practitioner expressed concerns about the decision to change the resident's code status, noting that it contradicted the resident's established advanced directives and could lead to unnecessary suffering. The facility had not updated the resident's guardianship or advanced directives following the spouse's death, resulting in a failure to honor the resident's end-of-life care preferences.
Neglect in Incontinence Care for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not implementing an established care plan for incontinence care. The resident, who was admitted in February 2011, has diagnoses including unspecified dementia with agitation, schizophrenia, epilepsy, and chronic systolic heart failure. The resident is severely cognitively impaired and dependent on staff for various activities, including toileting. Observations revealed that the resident was not provided with timely incontinence care on multiple occasions, despite being at risk for developing pressure ulcers. On specific dates, the resident was observed sitting in a Broda chair in the dining room for extended periods without staff checking for incontinence or providing necessary care. The care plan indicated that the resident required incontinence care every two hours and as needed, but this was not adhered to. Interviews with staff, including CNAs and a nurse, confirmed that the resident was not checked or changed in a timely manner, which is a neglect concern according to the facility's policy. The facility's policy on resident abuse and neglect emphasizes the importance of providing necessary care to avoid physical harm and mental anguish. Staff interviews revealed a lack of adherence to the care plan, with CNAs acknowledging that the resident had not received incontinence care since the morning. The Director of Nurses and Unit Manager also confirmed that the care plan should have been followed, and the failure to do so constitutes neglect.
Failure to Complete Restraint Assessment for Bed Equipment
Penalty
Summary
The facility failed to complete a restraint assessment for a resident before adding a bolster pillow to the resident's bed. The resident, who was admitted with dementia and had a moderate cognitive impairment, was observed with a bolster pillow tucked under the bedsheets on the edge of the bed. The facility's policy requires a written physician's order and a bed safety assessment before using any restraint or safety device, but the resident's records did not indicate the necessity of the bolster pillow, nor was it included in the bed safety assessments. Interviews with staff revealed that the bolster pillow was not assessed before being placed in the resident's bed. A CNA was unsure of the reason for the bolster pillow's presence, and a nurse confirmed that any equipment added to a resident's bed should be assessed beforehand. The clinical corporate nurse also stated that a bed safety assessment should have been completed prior to adding the bolster pillow, even if the resident or responsible party preferred it.
Failure to Follow Care Plans and Physician Orders for Resident Care
Penalty
Summary
The facility failed to adhere to the care plans and physician orders for three residents, leading to deficiencies in their care. Resident #25, who has severe cognitive impairment and is dependent on staff for bed mobility, was observed without the prescribed air mattress on multiple occasions. Despite the physician's order for an air mattress to be checked every shift, the resident's bed was equipped with a facility pressure-relieving mattress instead. Unit Manager #1 confirmed that the order for the air mattress was active and should have been followed. Resident #26, who is cognitively intact but dependent on staff for bed mobility, had a care plan intervention to offload heels while in bed. However, observations on consecutive days showed the resident's heels were directly on the bed without any offloading support. CNA #2 and Nurse #1 were unaware of the requirement, and there was no documentation of the resident refusing this intervention. Similarly, Resident #41, with severe cognitive impairment and dependent on staff for bed mobility, had a physician order to elevate the right heel for pressure relief. Observations revealed the resident's heels were not offloaded, and there was no record of refusal. Nurse #1 confirmed the oversight after speaking with the resident, who indicated that staff did not offload the heels as required.
Failure to Document Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with cardiomyopathy. The resident was prescribed metoprolol succinate with specific instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. During a medication pass, it was observed that the nurse administered the medication without documenting the required blood pressure parameters in the Medication Administration Record (MAR). The nurse indicated that the night shift was responsible for taking the blood pressure, but there was no documentation to confirm this. The Director of Nursing confirmed that physician orders should be followed and documented as required.
Failure to Conduct Weekly Skin Assessments for High-Risk Residents
Penalty
Summary
The facility failed to implement the medical plan of care for two residents who were assessed as high risk for developing pressure ulcers. Resident #28, admitted with conditions including dementia and Parkinson's disease, was identified as high risk for pressure ulcers based on the Norton Scale scores. Despite physician orders for weekly skin assessments, there was a four-week gap in documented skin checks between late June and late July. During an interview, the Unit Manager was unaware of the resident's risk level and confirmed the missed assessments upon reviewing the medical record. Similarly, Resident #32, with diagnoses such as congestive heart failure and diabetes, was also at high risk for pressure ulcers. The resident's care plan included weekly skin assessments, but checks were not completed on two specified dates. Interviews with nursing staff and the Director of Nursing revealed that the skin checks were supposed to be documented weekly, but were missed, indicating a failure to adhere to the physician's orders and care plan protocols.
Failure to Implement Hand Splint for Contracture Management
Penalty
Summary
The facility failed to implement the use of a hand splint for a resident with a right hand contracture, as per the rehabilitation plan of care. The resident, who has a history of cerebral infarction, hemiplegia, and hemiparesis affecting the right side, was observed on two separate occasions without the prescribed hand splint. The physician's order required the hand splint to be applied after nighttime care and removed before morning care to prevent further contracture development and skin breakdown. However, the resident was not wearing the splint during the surveyor's observations, and no splint was visible in the resident's room. Interviews with facility staff, including a Certified Occupational Therapy Assistant and the Occupational Therapist, revealed a lack of awareness and adherence to the physician's order for the hand splint. The Occupational Therapy Discharge Summary indicated that staff had previously been educated on the use of the splint, but there was no documentation of current range of motion values to monitor the contracture's progression. The Director of Nursing confirmed that all physician's orders should be followed, indicating a lapse in the facility's compliance with the resident's care plan.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to complete an investigation of a fall involving a resident, identified as Resident #12, who was admitted with diagnoses including respiratory failure and heart failure. The resident, who was cognitively intact and required substantial assistance for mobility tasks, reported a fall that occurred within the last year, which made them feel weaker. A referral for rehabilitation services was made following the fall, indicating that the resident rolled out of bed. However, the facility did not document the fall in the nursing notes, nor did they provide an incident report or conduct an investigation into the fall. Interviews with the Director of Rehabilitation (DOR) and the Corporate Nurse revealed that the fall was reported to the DOR, who then referred the resident to therapy. The DOR could not recall if the fall was reported to the nursing staff, who were responsible for conducting an investigation. The Corporate Nurse acknowledged that the therapy staff should have reported the fall to the nursing staff and confirmed that an investigation should have been conducted, regardless of the resident's history of sometimes reporting events that did not occur. The lack of an investigation into the fall constitutes a deficiency in the facility's adherence to its policy on accident and incident reporting.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management, as evidenced by several observations during a survey. Medications with short expiration dates were not dated when opened, and expired medications were not removed from supply. Specifically, Ocuflox eye drops were found open and undated, an earwax removal solution was expired since July 2024, and artificial tears had an expiration date of March 2024. During interviews, nurses acknowledged their responsibility to date medications when opened and to remove expired items, but these practices were not consistently followed. Additionally, the facility did not ensure that medications were securely stored. During a medication pass observation, a nurse left a medication cart unattended in the hallway, with multiple bottles of over-the-counter medications unsecured, while a resident was present in the area. On another occasion, a medication cart was left open and unattended on the second-floor unit, allowing a surveyor to access the drawer, with no nursing staff visible. The Director of Nursing confirmed that medication carts should be locked when not in use or when out of sight of the nurse.
Failure to Implement Correct Diet Texture for Resident
Penalty
Summary
The facility failed to provide the correct diet texture for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including cerebral infarction and moderate cognitive impairment, was observed eating meals that did not comply with the physician's order for a minced texture diet. Specifically, the resident was served a whole chicken cutlet and a whole sausage, neither of which were minced as required. The meal card on the resident's tray incorrectly indicated a regular diet, contributing to the oversight. Interviews with staff revealed a breakdown in communication regarding the resident's dietary needs. Nurse #2 acknowledged confusion about the meaning of a minced diet, and the Food Service Director stated that the kitchen staff relied on incorrect information from nursing slips. The Registered Dietitian admitted that the minced diet requirement was missed, and the Director of Nursing confirmed that there was miscommunication among staff. Despite the correct diet order being documented in the kitchen, it was not implemented, resulting in the resident receiving inappropriate meals.
Inaccurate Medical Record for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and diabetes, who was admitted in April 2018. The resident's physician orders from April 2023 required an air mattress to be checked for function and settings every shift. However, on August 13, 2024, observations revealed that the resident's bed had a facility pressure-relieving mattress instead of the prescribed air mattress. Despite this, the Medication Treatment Record inaccurately documented the presence of the air mattress on the same day. During an interview, a Unit Manager confirmed that the resident had not had an air mattress for at least two weeks and acknowledged that nurses should not mark an order as complete if it was not actually fulfilled.
Failure to Disinfect Blood Glucose Meter
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically regarding the cleaning of blood glucose meters. The facility's policy requires that all equipment be cleaned and disinfected with PDI sani-cloth germicidal disposable cloths after contact with a resident and before use on another resident. However, during an observation, a nurse was seen obtaining a resident's blood sugar and then exiting the room with the contaminated glucometer. The nurse placed the glucometer in a carrier case containing other supplies without disinfecting it. In an interview, the nurse acknowledged that the blood glucose meter should be sanitized after each use and stated that they use sani-cloth wipes for disinfection.
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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