Jml Care Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Falmouth, Massachusetts.
- Location
- 184 Ter Heun Drive, Falmouth, Massachusetts 02540
- CMS Provider Number
- 225369
- Inspections on file
- 15
- Latest survey
- February 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Jml Care Center Inc during CMS and state inspections, most recent first.
The facility failed to develop individualized care plans for four residents, leading to deficiencies in addressing their needs. One resident's care plan lacked targeted behaviors and measurable goals for Fluvoxamine use. Another resident's plan omitted Zyprexa and specific behaviors for psychotropic medications. A third resident's wound care was not documented, and a fourth resident's plan lacked details for Seroquel use. Staff acknowledged these oversights.
The facility failed to secure treatment supplies and manage sharps containers across three units. Unlocked utility rooms and supply closets allowed resident access to medicated supplies and hazardous items. Additionally, sharps containers were improperly managed, with protruding contaminated materials posing safety risks. Staff interviews confirmed these areas should have been secured to prevent resident access and ensure safety.
A facility failed to ensure proper monitoring of psychotropic medications for three residents. One resident was on Seroquel without clear target behaviors being documented, making it difficult to assess the medication's effectiveness. Another resident on fluvoxamine was not monitored for side effects during all shifts. A third resident on multiple psychotropic medications was not monitored for side effects of Escitalopram and Strattera, and monitoring for other medications was only done during the day shift. The DON acknowledged the need for consistent monitoring across all shifts.
The facility failed to screen and offer pneumococcal vaccinations to two residents upon admission, as required by policy and CDC guidelines. Both residents lacked signed consent forms and documentation of vaccine education. The Infection Preventionist confirmed the absence of follow-up processes with medical staff and residents regarding vaccination history and education.
A resident with Alzheimer's and vascular dementia fell, resulting in a large bruise, but the facility failed to notify the resident's Health Care Proxy as required by policy. Although the physician was informed, documentation did not show that the Health Care Proxy was notified, leading to a deficiency.
A facility failed to report an allegation of physical abuse involving a resident to the State Agency within the required timeframe. The resident, who had multiple medical conditions, reported being pushed and shoved by staff, and a family member observed fingerprint marks on the resident's arm. Despite the facility's policy to report such allegations within two hours, the administrator did not report it, citing a lack of further details from the resident and family member.
A facility failed to obtain a physician's order for oxygen administration for a resident receiving continuous oxygen therapy. The resident, who had chronic respiratory conditions, was observed using oxygen without a current order. Staff interviews revealed that the resident was on hospice care, and the oxygen was for comfort, but the Director of Nursing acknowledged that an order should have been in place.
A resident admitted with multiple health conditions did not receive a written summary of their baseline care plan, as required by facility policy. Interviews revealed that the resident and their family were not informed about the care plan, and there was no documentation of its receipt. Staff interviews indicated a lack of clarity and documentation regarding the process for reviewing and providing the baseline care plan to residents.
The facility failed to ensure that residents were seen by a physician every 60 days, as required. Medical records showed that residents had not been seen by a physician for extended periods, with all visits conducted by NPs. Interviews with staff revealed a lack of awareness regarding the schedule of physician visits, and the DON confirmed the required schedule was not being followed.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their care needs. A resident receiving dialysis was not coded for it, another receiving hospice services was not documented as such, and a third with a dementia diagnosis was not coded for dementia. These errors were confirmed by the MDS Nurse and acknowledged by the DON.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for four residents, leading to deficiencies in addressing their physical, psychosocial, and functional needs. For one resident with obsessive-compulsive disorder and depression, the care plan did not specify targeted behaviors for the use of Fluvoxamine, an antidepressant, nor did it include measurable goals to evaluate the medication's effectiveness and non-pharmacological interventions. This oversight was confirmed by the Unit Manager and the Director of Nursing (DON), who acknowledged the absence of specific, targeted behaviors and measurable goals in the care plan. Another resident with Alzheimer's disease, vascular dementia, and anxiety disorder was receiving multiple psychotropic medications, including Zyprexa, which was not included in the care plan. The care plan also lacked identification of resident-specific targeted behaviors for the use of antianxiety and antidepressant medications, as well as measurable goals to assess the effectiveness of these medications and non-pharmacological interventions. The Unit Manager and the DON both recognized the need for the inclusion of Zyprexa and the identification of targeted behaviors in the care plan. A third resident with peripheral vascular disease had an unhealed wound on the right medial calf, but the care plan did not include documentation related to this active wound or the resident's treatment by the Wound Clinic. The Unit Manager and the DON noted that the care plan should have been updated to reflect the resident's specific needs and treatment. Lastly, a resident with anxiety and Parkinson's disease was receiving Seroquel, an antipsychotic medication, but the care plan did not include a comprehensive plan for its use, including targeted signs/symptoms, resident-specific interventions, and measurable goals. The Unit Manager and the DON acknowledged the lack of an individualized care plan for the antipsychotic medication.
Facility Fails to Secure Treatment Supplies and Manage Sharps Containers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards across three units, as observed by surveyors. On the Naushon Unit, the Clean Utility Room was found unlocked, allowing access to medicated treatment supplies and an unlocked treatment cart. These supplies included various creams, ointments, and disinfectants, which should have been secured to prevent resident access. Interviews with staff revealed that the room lacked a lock due to the presence of an eye wash station, but treatment supplies should have been stored in a locked cabinet. On the Nobska Unit, similar issues were observed with the Clean Utility Room being unlocked and accessible, containing medicated treatment supplies and an unlocked treatment cart. Additionally, the Daily Supply Closet was found with the key left in the lock, making it accessible to residents. This closet contained items such as razors and alcohol-based products, posing a safety risk. Staff interviews confirmed that these areas should have been secured to prevent resident access. For Resident #33 on the Nobska Unit, a sharps container was observed with a blood-filled tubing protruding, posing a risk of needlestick injuries and exposure to bloodborne pathogens. Similarly, in Resident #73's room on the Penzance Unit, a sharps container was overfilled with contaminated materials protruding, increasing the risk of exposure. Interviews with staff indicated a lack of routine checks and replacement of sharps containers, contributing to these safety hazards.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not adequately identify and monitor target behaviors related to the use of Seroquel, an antipsychotic medication. The resident, who had diagnoses including anxiety and Parkinson's disease, was receiving Seroquel without a clear indication for its use. Interviews with staff revealed inconsistencies in understanding and documenting the resident's behaviors, such as hallucinations and calling out, which were not accurately reflected in the behavior monitoring sheets. This lack of specific documentation made it difficult to assess the effectiveness of the medication. Another resident, diagnosed with obsessive-compulsive disorder and depression, was receiving fluvoxamine, an antidepressant, with an increased dose. However, the facility failed to monitor the resident for potential side effects of the medication during all shifts. Monitoring was only conducted during the evening shift, neglecting the day and night shifts. This oversight in monitoring could potentially overlook adverse effects that may occur outside the evening shift. A third resident, with diagnoses including Alzheimer's disease, vascular dementia, and anxiety disorder, was on multiple psychotropic medications, including Ativan, Depakote, Remeron, Zyprexa, and Strattera. The facility failed to monitor for side effects of Escitalopram and Strattera and only monitored for side effects of other medications during the day shift. The Director of Nursing acknowledged that monitoring should occur during all shifts and for all medications, indicating a lapse in the facility's adherence to its own policies regarding medication monitoring.
Failure to Screen and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents were properly screened and offered the pneumococcal vaccination upon admission, as required by their own policy and CDC guidelines. Resident #33, admitted in February 2024, did not have a signed Immunization Consent form indicating consent or declination of the pneumococcal vaccine. Additionally, the Medication Reconciliation form for this resident did not indicate a history of pneumococcal vaccination and was not signed by a physician or nurse practitioner. There was also no documentation of education provided to the resident about the vaccine. The Massachusetts Immunization Information System (MIIS) form indicated that Resident #33 had received a pneumococcal vaccine in June 2016. Similarly, Resident #67, admitted in June 2024, also lacked a signed Immunization Consent form and the Medication Reconciliation form did not reflect any history of pneumococcal vaccination. There was no evidence that education about the vaccine was provided to this resident either. The MIIS form showed that Resident #67 had received a pneumococcal vaccine in February 2016. During an interview, the Infection Preventionist acknowledged the lack of follow-up with the physician or nurse practitioner regarding vaccination history and recommendations, and the absence of a process to follow up with residents or their representatives about vaccination history and education after admission.
Failure to Notify Health Care Proxy of Resident Fall
Penalty
Summary
The facility failed to notify the Health Care Proxy of a resident who experienced a fall, resulting in a deficiency. The resident, who was admitted in October 2023, had diagnoses including Alzheimer's disease, vascular dementia, and anxiety disorder. The Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and an activated Health Care Proxy. On January 19, 2025, the resident fell and sustained a large bruise on the midback. Although the resident's physician was notified, there was no documentation indicating that the Health Care Proxy was informed of the incident. The facility's policies require that both the physician and the responsible party be notified at the time of such occurrences, with documentation in the incident report and nurse's notes. However, a review of the medical record and fall incident report revealed a lack of evidence that the Health Care Proxy was notified. Interviews with the Unit Manager and the Director of Nursing confirmed that the notification should have been made and documented, but it was not, leading to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State Agency within the mandated timeframes. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but no later than two hours after the allegation is made. In this case, a resident reported to a surveyor that staff were pushing and shoving them late at night, and a family member observed fingerprint marks on the resident's arm, suggesting possible abuse. However, the facility did not report this allegation to the State Agency as required. The resident involved had a history of multiple medical conditions, including an open wound, atrial fibrillation, sleep apnea, major depressive disorder, venous insufficiency, falls, and hearing loss. Despite the resident being cognitively intact, as indicated by a BIMS score of 13 out of 15, the facility's administrator did not report the allegation because the resident and family member did not provide further details. The administrator acknowledged that the report should have been made within two hours but was not, and an investigation was in progress at the time of the surveyor's interview.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was receiving continuous oxygen therapy. The resident, who had multiple diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease, was observed using a nasal cannula connected to an oxygen concentrator delivering 2 liters per minute of oxygen. However, a review of the resident's current physician's orders revealed that there was no order for the administration of oxygen, which is considered a medication and should be prescribed. Interviews with nursing staff and the Director of Nurses (DON) revealed that the resident was admitted to hospice care for symptom management, and the oxygen was being used for comfort. Despite this, the DON acknowledged that there should have been an order for oxygen, as it is a medication. The order for oxygen was initially entered and signed off by the physician but was discontinued the same day without a clear reason. The DON explained that the Unit Manager discontinued the order because it was a titrated order requiring monitoring and forgot to enter a new order for oxygen for comfort measures.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a resident with a written summary of the baseline care plan upon admission, as required by their policy. The baseline care plan should include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The resident, who was admitted with diagnoses including morbid obesity, type 2 diabetes mellitus, uncontrolled hypertension, coronary artery disease, and a history of falls, did not receive this summary, nor was there documentation of its receipt in the resident's clinical record. Interviews with the resident and their daughter revealed that no care plan meeting occurred within the first several days of admission, and they did not receive a copy of the care plan. The resident expressed that they had not been informed about their care plan and had not seen the social worker until much later. The social worker confirmed that while she met with the resident for an assessment, she did not review a summary of the baseline care plan with them, and there was no documentation to indicate that the resident or their representative received this information. Further interviews with facility staff, including a nurse and the Director of Nurses (DON), indicated a lack of clarity and documentation regarding the process for reviewing and providing the baseline care plan to residents. The DON acknowledged the absence of a signed or dated baseline care plan in the resident's record, which would have confirmed that the plan was reviewed with the resident. This deficiency highlights a failure in the facility's process to ensure that residents are informed of their care plans upon admission.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that five residents were seen by a physician every 60 days, as required by regulations. The facility's policy stated that after the first 90 days, residents should be seen by a physician every 60 days, with visits alternating between a physician and a nurse practitioner (NP). However, the review of medical records indicated that these residents had not been seen by a physician for extended periods, ranging from 238 to 287 days, with all subsequent visits being conducted by NPs. Interviews with facility staff, including nurses and unit managers, revealed a lack of awareness regarding the schedule and frequency of physician visits. Nurse #1 and Unit Manager #2 both indicated that residents were typically seen by NPs, and they were unsure of when physicians visited the facility. The Director of Nursing (DON) confirmed that residents should be seen by a physician every 30 days for the first 90 days and then every 60 days thereafter, alternating with NPs, but was unaware that this schedule was not being followed. The deficiency was identified through a review of physician progress notes and interviews with facility staff. The facility's failure to adhere to the required schedule of physician visits resulted in residents not being seen by a physician for significant periods, contrary to the facility's policy and regulatory requirements.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care needs. Resident #70, who was admitted with end-stage renal disease and vascular dementia, was receiving dialysis as per physician's orders. However, the MDS assessment did not reflect this, indicating a failure to accurately code for dialysis. During an interview, MDS Nurse #1 acknowledged the error and stated that the assessment needed modification. Similarly, Resident #6, admitted with dementia and anxiety, was receiving hospice services as indicated by physician's orders. Yet, the MDS assessment failed to document this, which was confirmed by MDS Nurse #1 during an interview. Additionally, Resident #33, who had a documented diagnosis of dementia in multiple physician's progress notes, was not coded for dementia in the MDS assessment. MDS Nurse #1 confirmed the oversight after reviewing the resident's notes. The Director of Nursing stated that the expectation was for all MDS assessments to be completed accurately.
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 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.
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.
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.
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.
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 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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