John Scott House Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Braintree, Massachusetts.
- Location
- 233 Middle Street, Braintree, Massachusetts 02184
- CMS Provider Number
- 225054
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at John Scott House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation, and with an invoked HCP, was found on the floor by one nurse, who then sought assistance from another nurse. After the resident was assessed and returned to bed, neither nurse completed required fall documentation or notified the physician or HCA, each assuming the other would do so. The fall was not reported to clinical leadership until later, and the physician was not documented as being notified until several days after the event. A family member later observed a bruise near the resident’s eye during a visit and reported that no one from the facility had informed her of the fall.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation use was found on the floor next to the bed after an unwitnessed fall. Two nurses assisted the resident back to bed, but no immediate VS, neuro checks, or fall, skin, or pain assessments were completed, and no incident report, physician/family notification, or timely nursing note was done as required by facility policy. Each nurse assumed the other would complete the necessary documentation and notifications, and the event was not reported to management the same day, resulting in a failure to provide and document post-fall care in accordance with professional standards.
Surveyors found that the facility did not ensure a clean, comfortable, and homelike environment, with multiple areas in disrepair such as broken heaters, peeling molding, wall cracks, and water damage in resident rooms and common areas. Residents reported a lack of visible maintenance activity, and incomplete work orders were discovered. Additionally, a window air conditioner was found with visible black spots and a dust-laden filter, indicating poor maintenance practices.
A resident who was cognitively intact and dependent on staff for personal hygiene expressed a clear wish to grow a handlebar mustache and not have it trimmed. Despite this, staff continued to trim the mustache against the resident's wishes, and the care plan did not reflect the resident's preference. Staff interviews confirmed that the resident's requests were disregarded, resulting in a failure to respect the resident's dignity and self-determination.
A resident with dementia and oropharyngeal dysphagia required supervision and verbal cues for safe swallowing during meals, as outlined in the care plan and recommended by the SLP. Surveyors observed the resident eating alone in bed or in the day room without consistent staff supervision or cueing, and staff interviews revealed a lack of understanding and implementation of the required interventions. This failure to follow the care plan and SLP recommendations resulted in a deficiency.
A resident was not seen by a physician or NP at the required 60-day intervals, with gaps of 76 and 114 days between visits, and no documentation of a provider visit for 158 days. The deficiency was due to missed visits and incomplete documentation following a change in the physician's record-keeping system.
Surveyors found that the facility did not maintain the main kitchen floor and walls in a sanitary condition, with cracked and receded grout, debris, water accumulation, and damaged wall coverings behind the three-bay sink. The FSD and Administrator confirmed that these areas should be intact and easily cleanable to meet food safety standards.
Handrails on one unit were found to be loose and easily moved in several areas, while residents were observed walking in the affected hallway. The DON confirmed that handrails should be securely attached for resident use, and the Administrator noted there was no specific process for identifying and reporting broken handrails, depending on staff to inform maintenance when issues arise.
A resident with severe cognitive impairment and multiple health issues experienced a significant decline in condition, requiring new medical orders. The facility failed to promptly notify the resident's Health Care Agent (HCA) of these changes, as required by policy. The HCA was only informed two days later, despite the facility's expectation for timely communication.
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The residents were not offered the PCV 20 vaccine as required, and staff interviews revealed a lack of clarity and responsibility in ensuring vaccinations were administered. The Infection Prevention Nurse and Director of Nurses acknowledged the deficiencies and the need for improvement.
The facility failed to develop person-centered care plans that included trauma-informed approaches and identified triggers for two residents with a history of trauma and PTSD. Incomplete assessments and care plans, along with a lack of staff awareness, led to deficiencies in providing appropriate care.
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident with Bullous Pemphigoid and colonized with ESBL bacteria. Nurse #1 did not wear a protective gown during the procedure, despite clear signage and physician's orders. The ADON and DON confirmed that gown and gloves were required for high-contact care activities for residents on EBP precautions.
Failure to Notify Physician and Health Care Agent After Resident Fall
Penalty
Summary
Staff failed to promptly notify a resident’s physician and Health Care Agent (HCA) after the resident experienced a significant change in status related to a fall. The resident had been admitted with diagnoses including status post fall with a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use, and had an invoked Health Care Proxy. Facility policy required prompt notification of the resident, physician, and resident representative of changes in medical or mental condition, including accidents or incidents. On the morning in question, one nurse (Nurse #2) found the resident on the floor next to the bed and obtained the assigned nurse (Nurse #1) to assist. After assessing the resident for injury and returning the resident to bed, neither nurse completed the required fall documentation or made the required notifications to the physician or HCA at that time. Nurse #1 stated that at the end of her shift she had not completed any documentation related to the fall and assumed Nurse #2 would do so, and confirmed she did not notify the physician or HCA. Nurse #2 stated she assumed Nurse #1 would complete the documentation and notifications and did not verify that this occurred, and did not report the fall to anyone until the following morning during nurse-to-nurse report; she later entered a late note about the incident. Review of the medical record showed no documentation that the unwitnessed fall was reported to the physician until several days later. The Staff Development Coordinator and DON both reported they were unaware of the fall until the DON began an investigation into a bruise of unknown origin near the resident’s right eye, which had been identified by the resident’s HCA during a visit. A family member reported discovering the bruise during a visit and being told by a nurse that the resident had likely fallen the previous day, and also reported that no one from the facility had notified her of the fall.
Failure to Assess and Document Care After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality following an unwitnessed fall. A resident with a history of a fall resulting in a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use was admitted in 10/2025. On 10/27/25 at approximately 7:15 A.M., the resident was found on the floor next to the bed by one nurse (Nurse #2), who then notified the assigned nurse (Nurse #1). Both nurses assisted the resident back into bed. Facility policy required that any fall, including unwitnessed falls, be followed by physician and family notification, completion of a fall incident report and fall investigation, monitoring of vital signs, and neurological checks. Nurse #1 reported that, because it was the end of her shift and Nurse #2 told her not to worry about the documentation, she did not obtain vital signs, did not perform neurological checks, and did not complete any fall, skin, or pain assessments, incident report, or timely nursing progress note for the event, only entering a late note on 11/04/25. Nurse #2 stated she assumed Nurse #1 would complete the required documentation and did not follow up or report the incident to anyone that day, only mentioning it the following morning in report. The Staff Development Coordinator and DON both stated they were not aware the resident had been found on the floor on 10/27/25 until a bruise of unknown origin was identified by the resident’s health care proxy on 10/28/25, and both confirmed that the facility’s expectation is that the responding nurse immediately assess the resident and complete all required assessments, vital signs, neurological checks, and notifications after any witnessed or unwitnessed fall.
Failure to Maintain Clean, Homelike, and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness across two of four units. Specific issues included a baseboard heater in pieces on the floor, peeling and damaged molding, cracks and holes in walls, chipped paint, and scratched walls in resident rooms and common areas. Residents reported that maintenance staff were rarely seen performing repairs or preventative maintenance, and some stated that visible damage had been present since before their admission. Review of work order slips revealed incomplete and unsigned requests, indicating lapses in the maintenance process. Further deficiencies were observed in the Whirlpool tub room and an adjacent resident room, where there was evidence of water damage such as brown discoloration, bubbling and chipped paint, and bowed or cracked plaster on ceilings and walls. Maintenance staff acknowledged that these issues were related to recurring water leaks from an upstairs tub room and that previous patching and painting had not resolved the problem. The administrator was unaware of the ongoing water leakage and the extent of the damage until it was pointed out during the survey. Additionally, a window air conditioner in a resident room was found to be in poor condition, with visible black spots on the vents and a filter heavily laden with dust. The maintenance director confirmed that air conditioners are typically cleaned before storage, but if a resident requests year-round use, housekeeping is expected to notify maintenance for cleaning. In this case, the air conditioner had not been properly maintained, as evidenced by the accumulation of dust and debris.
Failure to Honor Resident's Personal Grooming Preferences
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not respecting the resident's expressed wish to grow a handlebar mustache. The resident, who was cognitively intact with a BIMS score of 14 and dependent on staff for personal hygiene due to hemiplegia following a stroke, repeatedly communicated to staff that he did not want his mustache trimmed. Despite these clear wishes, staff continued to trim his mustache against his instructions. The care plan did not document the resident's preference regarding his mustache, and staff interviews confirmed that they trimmed the mustache even when the resident objected. Observations showed the resident's mustache was initially long and curling into his mouth, but later had been trimmed without his consent. The resident reported that staff ignored his requests and trimmed his mustache anyway, leaving him feeling disregarded. Staff interviews corroborated that the resident did not want his mustache touched, but they proceeded to trim it, sometimes justifying it as necessary for hygiene. The facility's own policy emphasized the importance of respecting resident rights and preferences, but this was not followed in the resident's care.
Failure to Implement Safe Swallowing Interventions for Resident with Dysphagia
Penalty
Summary
The facility failed to implement the person-centered care plan interventions for a resident with oropharyngeal dysphagia, resulting in a lack of adherence to safe swallowing strategies. The resident, who had dementia and dysphagia, was assessed as having moderate cognitive impairment and required a mechanically altered diet with supervision for eating. The care plan and dining needs list indicated the resident was independent with eating but required 1:8 supervision and intermittent cues. Speech therapy notes documented the need for the resident to be upright and out of bed for meals, to alternate solids and liquids, and to receive verbal cues to promote safe swallowing. Despite repeated education to nursing staff by the SLP, the resident was frequently observed eating alone in bed, not always upright, and without consistent staff supervision or cueing as recommended. Observations by the surveyor showed the resident eating meals alone in bed on multiple occasions, with visual aids present but not always followed, and without staff providing the necessary verbal cues to alternate solids and liquids. On one occasion, the resident was observed in the day room for breakfast but did not receive staff cues to alternate solids and liquids, and the visual aids were not present. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with some staff unaware of the specific cues required or the importance of supervision during meals. Staff also reported challenges with the resident refusing assistance and the need for multiple staff to assist with getting the resident out of bed, which sometimes resulted in the resident remaining in bed for meals. The SLP confirmed that the resident required intermittent supervision and verbal cues to use safe swallowing strategies, and that staff had been educated on these needs. However, the care plan lacked specific details on the cues required, and staff did not consistently provide the recommended supervision or cueing during meals. The failure to implement the care plan interventions as recommended by the SLP and documented in the resident's care plan led to the deficiency identified during the survey.
Failure to Ensure Timely Physician/NP Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician or nurse practitioner (NP) at the required intervals as outlined in both facility policy and regulatory requirements. According to the facility's policy, residents must be reassessed and have an updated medical care plan at least every 30 days for the first 90 days after admission, and every 60 days thereafter. Record review showed that the resident was seen by a physician on 4/16/24 and by an NP on 7/2/24, resulting in a 76-day gap between visits, which exceeds the required 60-day interval. Further review indicated that after the NP's visit on 7/2/24, the next documented provider visit was not until 10/25/24, a gap of 114 days, and there was no documentation of any provider visit for 158 days following the 10/25/24 visit. Interviews with the Clinical Nurse Consultant confirmed that the physician and NP were expected to visit the facility weekly, but documentation showed that the resident had not been seen by a provider since October 2024. The physician was unable to provide additional documentation of visits due to a transition to new documentation software, which contributed to the lack of timely and complete records. The deficiency was attributed to an oversight in both the scheduling of visits and the maintenance of proper documentation.
Failure to Maintain Sanitary Kitchen Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain the main kitchen floor and ceiling in a sanitary and safe condition, as required by professional standards for food safety and sanitation. Specifically, there were multiple instances of cracked, crumbled, and receded floor grout throughout the kitchen, including at the floor-wall joint and inside the walk-in refrigerator. These areas contained settled debris and water. Additionally, the wall covering behind the three-bay sink was uneven and missing in places, with visible openings in the wall. These conditions were directly observed by surveyors during their inspection. Interviews with the Food Service Director (FSD) confirmed that most of the kitchen flooring and grouting was original to the building and had not been fully repaired, except for some small areas. The FSD acknowledged that the kitchen walls should not have holes or protruding coverings and that the flooring should be easily cleanable and free from debris or moisture. The Administrator also stated that the kitchen walls and flooring should be in good condition, without holes or compromised areas that could harbor debris or moisture, and that the kitchen should be maintained in a safe and sanitary condition.
Handrails Not Securely Affixed in Hallway
Penalty
Summary
The facility failed to ensure that handrails on the East 2 unit were securely affixed to the wall. During an observation, a surveyor was able to move three separate pieces of handrails with minimal effort in different areas of the unit, indicating that the handrails had come loose from the wall. Residents were observed walking in the hallway where the loose handrails were present. The DON confirmed that all handrails should be securely attached, as they are used by residents. The Administrator acknowledged the concern and stated that there was no specific process in place for identifying broken handrails, relying instead on staff to report issues to the maintenance department.
Failure to Notify Health Care Agent of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify the Health Care Agent (HCA) of a resident who experienced a significant decline in condition, which necessitated new physician's orders and changes in the treatment plan. The resident, who was admitted in February 2023, had a history of Alzheimer's type dementia, acquired hypothyroidism, a left parotid mass, dysphagia, and chronic stage three kidney disease. The Health Care Proxy (HCP) for the resident had been invoked, indicating that the HCA should be informed of any significant changes in the resident's condition. On March 18, 2024, the resident exhibited signs of a decline, including a fever of 102.1 degrees Fahrenheit, lethargy, and low oxygen saturation levels, which required the administration of oxygen and other medical interventions. Despite these significant changes, there was no documentation to support that the nursing staff notified the HCA of the resident's condition on March 18 and March 19, 2024. The HCA was only informed on March 20, 2024, which was the first time she was made aware of the resident's medical decline and the need for oxygen. Interviews with the nursing staff, including a nurse, the Unit Manager, the Assistant Director of Nurses (ADON), and the Director of Nurses (DON), revealed that the facility's policy required prompt notification of the HCA in such situations. However, the staff could not confirm that the HCA was informed in a timely manner, as expected by the facility's policy. The lack of timely communication with the HCA regarding the resident's significant change in condition constituted a deficiency in the facility's adherence to its notification policy.
Failure to Provide Pneumococcal Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The facility's policy required offering the Pneumococcal conjugate vaccine (PCV 13, PCV 15, or PCV 20) based on availability and previous vaccination history, and ensuring informed consent with the most current literature on the risks and benefits. However, the facility did not adhere to these guidelines, resulting in residents not being offered the PCV 20 vaccine as recommended by the CDC for adults 65 and over who had not received prior pneumococcal vaccines or had received them more than five years ago. Resident #9, admitted in May 2022, had received PPSV 23 in 2014 but was never offered the PCV 20 vaccine since admission. The resident, who is cognitively intact, expressed interest in receiving the vaccine but was unaware of its availability. Resident #67, admitted in March 2021, had received PPSV 23 and PCV 13 in November 2021, but there was no evidence that the PCV 20 vaccine was ever offered to the resident or their healthcare proxy. Resident #52, admitted in January 2024, had no information regarding pneumococcal vaccinations in their immunization record, and the consent form was incomplete, with no follow-up to readdress the vaccinations. Interviews with staff revealed a lack of clarity and responsibility in ensuring residents received the necessary vaccinations. The Unit Managers and nurses indicated that immunization consents were completed upon admission, but there was no process for re-offering vaccinations or ensuring follow-up. The Infection Prevention Nurse acknowledged the deficiencies and the need for improvement in the vaccination process, while the Director of Nurses admitted that the facility's policy was not being followed as it should be.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for two residents. For one resident with a history of PTSD, the facility did not identify specific triggers related to their trauma, despite the resident's active diagnosis and ongoing psychotherapy sessions. The resident's care plan and assessments were incomplete and did not reflect the necessary information to prevent re-traumatization. Interviews with staff revealed a lack of awareness of the resident's specific triggers, and the Director of Social Services acknowledged the deficiencies in the assessments and care plan documentation. For another resident, the facility did not complete a trauma assessment, resulting in a failure to provide trauma-informed care. The resident, who had multiple diagnoses including a traumatic amputation and cerebral palsy, was not assessed for past trauma upon admission. The social worker admitted that a comprehensive psychosocial assessment was not completed, and the resident confirmed that they had not been asked about past traumas or triggers. The resident had experienced significant traumatic events, but this information was not documented or communicated to the facility staff. The facility's policy on trauma-informed care and PTSD was not followed, as evidenced by the incomplete assessments and care plans for both residents. The policy required interdisciplinary assessment and the development of care plans that included potential triggers and interventions to avoid re-traumatization. However, the facility failed to gather and document the necessary information to provide appropriate care for residents with a history of trauma and PTSD.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident diagnosed with Bullous Pemphigoid and colonized with Extended Spectrum Beta-Lactamase (ESBL) bacteria in the urine. The facility's policy required the use of gown and gloves during high-contact care activities, including wound care, for residents on EBP precautions. However, during an observation, Nurse #1 did not don a protective gown while providing wound care to the resident's bilateral breast wounds, despite the clear signage on the resident's door and the physician's orders indicating the need for EBP precautions. During interviews, Nurse #1 acknowledged the failure to wear a protective gown, and both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact care activities for residents on EBP precautions. The ADON and DON reiterated that the resident was on EBP precautions due to an MDRO infection, and gown and gloves were required for wound care, even though the wounds were not draining any fluid.
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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