Julian J Levitt Family Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Longmeadow, Massachusetts.
- Location
- 770 Converse Street, Longmeadow, Massachusetts 01106
- CMS Provider Number
- 225040
- Inspections on file
- 21
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Julian J Levitt Family Nursing Home during CMS and state inspections, most recent first.
The facility did not maintain an up-to-date and complete infection line listing as required by its infection control policies, resulting in inadequate tracking and monitoring of infections. The Infection Preventionist relied on incomplete monthly antibiotic use lists, and the Infection Tracker Line Listing lacked essential information such as room numbers and specific signs and symptoms. Discrepancies between tracking tools and inconsistent data entry by staff further contributed to the deficiency, placing residents at risk for inadequate infection monitoring.
A resident requiring staff assistance for ADLs was left exposed and uncovered by a CNA during personal care, despite requesting to be covered. The resident reported feeling disrespected and undignified, and staff failed to promptly investigate or address the grievance, resulting in delayed follow-up and continued risk for undignified care.
A resident with a history of alcohol abuse and depression developed new diagnoses of psychosis and delusional disorder, but the facility did not refer the individual for a required PASRR Level II Evaluation after these changes in mental health status were identified. Record review and staff interview confirmed that the necessary referral was not made following the updated diagnoses.
A resident with a history of Myasthenia Gravis, dementia, and recurrent conjunctivitis did not receive Refresh Optive eye drops at the frequency recommended by an ophthalmologist. Although the consultant's recommendation to increase administration from twice to four times daily was reviewed and accepted by the provider, the order was not updated, and the resident continued to receive the drops only twice daily.
A resident with a history of hearing loss did not receive recommended follow-up care after an audiology consult identified impacted cerumen and hearing aid issues. The facility did not implement the audiologist's recommendations for wax removal or ensure proper use and maintenance of hearing aids, resulting in continued communication difficulties and lack of appropriate treatment.
A resident with epilepsy did not have a physician-ordered Keppra (Levetiracetam) level drawn due to the facility's failure to complete the necessary laboratory requisition, despite the medication being administered as ordered. Staff interviews confirmed the omission, and the clinical record lacked evidence of the required lab test, resulting in inadequate monitoring of the resident's medication level.
The facility did not consistently document critical clinical information for three residents, including missing post void residual measurements for a resident with kidney disease, lack of documentation for a newly ordered dose of Lasix for a resident with heart failure, and failure to record administration of PRN antipsychotic medication for a resident with dementia. Nursing staff interviews confirmed that required documentation was not always completed as ordered.
A resident with severe cognitive impairment and a history of falls was involved in an incident during a transfer using a Hoyer lift. Two CNAs failed to properly set up the lift by not widening the base legs, causing the lift to tip sideways. The resident was safely lowered to the floor without injury. Interviews revealed that the CNAs were unaware of the importance of opening the base legs for stability, indicating a gap in adherence to mechanical lift protocols.
A resident who required assistance from two staff members for bed mobility fell and sustained fractures when a CNA provided care alone, contrary to the care plan. The CNA was unaware of the requirement for two staff members and lowered the side rail at the resident's request, leading to the fall.
A resident who required two-person assistance for bed mobility and the use of bilateral side rails was not provided with the necessary support, leading to a fall and pelvic fractures. The CNA did not follow the care plan and proceeded without obtaining help from another staff member, resulting in the resident's injury.
A CNA violated the privacy of two severely cognitively impaired residents by using her personal cell phone for a non-work-related video call while providing care. The CNA did not obtain consent from the residents or their representatives, breaching the Facility's policies and the residents' right to privacy.
Failure to Maintain Comprehensive Infection Surveillance and Tracking
Penalty
Summary
The facility failed to implement an effective system of surveillance for infection tracking as required by its own Infection Prevention and Control Plan. The Infection Preventionist (IP), who was new to the role, was responsible for maintaining an up-to-date infection line listing but had not started the line listing for the month of April at the time of the survey. Instead, the IP relied on a monthly line listing that only tracked residents on antibiotics, which lacked several required data elements such as date of admission, date of onset of symptoms, specific signs and symptoms, and organism(s). Additionally, the line listing did not include resident room numbers, and some entries were incomplete, such as missing antibiotic information for certain residents. The facility maintained two separate tracking tools: a Line Listing for Antibiotic Use and an Infection Tracker Line Listing. The Infection Tracker Line Listing, which was intended to track all infections, also lacked critical information, including resident room numbers and specific signs and symptoms of infection. There were discrepancies between the two lists, with some residents appearing on one list but not the other, and the Infection Tracker Line Listing was not consistently updated by the Unit Managers as required. The DON acknowledged these gaps and stated that the Infection Tracker Line Listing should be used for all infections and that missing information was due to staff not entering data as expected. The facility's policies and infection control plan emphasized the importance of surveillance, including the collection and analysis of infection data to identify trends, clusters, and patterns. However, the lack of a comprehensive, up-to-date, and accurate infection line listing, as well as incomplete documentation of required information, resulted in inadequate monitoring and tracking of infections. This failure placed residents at risk for insufficient infection monitoring and potential spread of infections within the facility.
Failure to Maintain Resident Dignity and Timely Response to Grievance
Penalty
Summary
A resident with osteoarthritis, muscle weakness, and significant limitations in activities of daily living (ADLs) required staff assistance for personal care, including dressing, bathing, and mobility. During a night shift, a CNA assisted the resident after a bedpan incident resulted in soiled bedding and gown. While changing the resident and the bed linens, the CNA removed the resident's hospital gown and left the resident exposed and uncovered in bed. The resident requested to be covered due to feeling cold, but the CNA did not respond, left the resident exposed, and exited the room to get supplies. The resident reported feeling disrespected, undignified, and dehumanized by this experience. The resident communicated the incident to multiple staff members the following morning, including a nurse, rehabilitation staff, and later to the unit manager and social worker. Despite these reports, there was a significant delay in staff response and investigation. The resident was not promptly interviewed about the incident, and the grievance process was not initiated in a timely manner. The CNA involved returned to the resident's room later that day, despite the resident's expressed wishes not to receive care from that CNA, and only left after being told by the resident about the complaint. Interviews with staff revealed confusion and lack of clarity regarding the grievance process and timely follow-up. The social worker did not return to the resident until several hours after the initial report, and the grievance form was not processed or followed up on until brought to the attention of surveyors. The resident did not receive communication about the outcome of the complaint until much later, and staff failed to ensure the resident's dignity and respect during personal care, as well as a timely and appropriate response to the resident's concerns.
Failure to Refer Resident for PASRR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation after the identification of a new serious mental health diagnosis. The resident was originally admitted with a history of alcohol abuse and depression, and the initial PASRR completed at admission did not indicate the need for a Level II Evaluation. Over time, the resident's diagnoses expanded to include dementia, anxiety, psychosis, and delusional disorder, with the diagnosis of psychosis and delusional disorder being documented on 9/26/24. A behavioral health note from 3/29/23 also indicated the presence of psychosis, but there was no evidence in the medical record that a PASRR Level II Evaluation was conducted following these new or newly evident diagnoses. During an interview, the facility's social worker confirmed that a request for a PASRR Level II Evaluation should have been made when the new mental health diagnosis was identified, but this referral was not completed as required. The deficiency was identified through record review and staff interview, which confirmed the lack of appropriate referral for further evaluation after the resident's mental health status changed.
Failure to Update Eye Drop Administration per Ophthalmologist Recommendation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow up on an ophthalmologist's recommendation to increase the administration of Refresh Optive Mega-3 Ophthalmic Solution from two times per day to four times per day. The recommendation was documented in a consultation report and reviewed and accepted by the facility provider, as indicated by their initials. However, the physician order for the eye drops remained at two times per day, and the medication administration records showed that the resident continued to receive the drops only twice daily. The resident involved had a history of Myasthenia Gravis, dementia, bilateral ectropion, and recurrent conjunctivitis. During an observation, the resident was noted to have red, watery lower eyelids and a yellow crusty substance on the left upper lid. Interviews with staff confirmed that the process for updating the medication order after a consultant's recommendation was not followed, resulting in the resident not receiving the increased frequency of eye drops as recommended by the ophthalmologist.
Failure to Implement Audiology Recommendations for Hearing Loss
Penalty
Summary
The facility failed to implement audiology recommendations for a resident with a history of hearing loss, resulting in a lack of appropriate treatment for the resident's condition. The resident, who was cognitively intact and required assistance with personal care, had a care plan in place that included audiology consults and the use of assistive hearing devices. Despite a documented audiology consult in January 2025, which identified impacted cerumen in the left ear, a perforated tympanic membrane in the right ear, and issues with hearing aid function, the recommended follow-up actions were not carried out by the facility. The audiologist's recommendations included removal of earwax in the left ear, a medical consult for wax removal, and specific instructions for hearing aid maintenance and use. However, there was no evidence in the clinical record that these recommendations were reviewed or implemented by the provider or nursing staff. The consult form was not initialed as reviewed, and no new orders for wax removal were found in the resident's record. Staff interviews confirmed a lack of awareness regarding the resident's hearing aids and the audiologist's recommendations, and the hearing aids were found unused in the resident's room. Observations during the survey revealed that the resident continued to experience significant hearing difficulties, relied on a white board for communication, and was not using hearing aids. The resident reported ongoing issues with hearing, wax buildup, and lack of follow-up after the audiology appointment. Facility staff, including the unit manager and CNA, were unaware of the resident's hearing aid use and the need for follow-up care, further demonstrating the facility's failure to ensure the audiologist's recommendations were implemented.
Failure to Obtain Ordered Laboratory Test for Medication Monitoring
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident with epilepsy who was maintained on Keppra (Levetiracetam) for seizure management. The physician assistant documented a decline in the resident's status and weight loss, and ordered a Keppra level to be drawn on a specific date. Review of the resident's clinical record and medication administration record showed that while Keppra was administered as ordered, there was no evidence that the Keppra level was drawn as required. The medication administration record indicated the lab order was blocked off, and no laboratory requisition slip was found to confirm the test was performed. Interviews with facility staff revealed that the Keppra level was not drawn because the necessary laboratory requisition had not been completed by the facility. The DON acknowledged that the absence of the lab requisition resulted in the test not being performed, and confirmed that the resident's clinical record did not contain evidence of the required lab draw. This failure to obtain the ordered laboratory test resulted in inadequate monitoring of the resident's medication level.
Failure to Maintain Complete and Accurate Clinical Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, resulting in deficiencies related to documentation of critical medical information. For one resident with a history of urinary tract infection, acute kidney failure, and chronic kidney disease, physician orders required post void residual (PVR) measurements every shift for three days. However, the clinical record lacked documentation of PVRs for two evening shifts, and interviews with nursing staff revealed that the measurements may have been completed but were not consistently recorded in the resident's record as required. Another resident with acute on chronic heart failure and ischemic cardiomyopathy was ordered to receive Lasix 20 mg in the evening for three days following a weight gain. The medication administration record showed that Lasix was given on the second and third days, but there was no documentation of administration on the first day as ordered. Nursing staff confirmed that the medication was not signed off as given, and acknowledged that it should have been documented if administered. A third resident, admitted with vascular dementia and severe cognitive impairment, had a physician order for PRN Seroquel to manage agitation. The medication card indicated that doses had been removed, but there was no corresponding documentation in the medication administration record or progress notes to confirm administration. Nursing staff admitted to administering the medication without always documenting it, and the DON confirmed that the required documentation was not consistently completed.
Improper Use of Hoyer Lift Leads to Resident Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident who required the use of a Hoyer lift for transfers. On the morning of November 19, 2024, two CNAs, CNA #3 and CNA #4, were responsible for transferring the resident from bed to a wheelchair using the Hoyer lift. During the transfer, the CNAs did not properly set up the lift by failing to widen the base legs, which are crucial for stability. As a result, the lift began to tip sideways, and the resident was lowered to the floor by the CNAs to prevent injury. The resident involved had a history of severe cognitive impairment and was dependent on staff for transfers, as indicated in their care plan. The resident had been admitted to the facility earlier in the year with diagnoses including dementia and recent falls that resulted in a subdural hematoma, subgleal hematoma, and subarachnoid hemorrhage. Despite these conditions, the resident did not sustain any new injuries during the incident, and no signs of pain were observed by the attending nurse. Interviews with the CNAs and other staff revealed a lack of understanding regarding the proper use of the Hoyer lift. Both CNAs admitted to not realizing the importance of opening the base legs for stability during the transfer process. The facility's investigation and re-enactment of the incident confirmed that the failure to open the base legs led to the lift tipping over. This deficiency highlights a gap in the staff's knowledge and adherence to the facility's mechanical lift protocols, which contributed to the unsafe transfer of the resident.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The Facility failed to ensure staff implemented and followed interventions in a resident's care plan, resulting in the resident falling out of bed and sustaining fractures. The resident, who required assistance from two staff members for bed mobility, was being cared for by a single CNA. During the care, the CNA rolled the resident onto their side without another staff member present, causing the resident to fall off the bed and land on the floor, leading to acute non-displaced fractures of the right superior and inferior pubic rami. The resident was subsequently transferred to the hospital for evaluation and treatment. The resident had a comprehensive care plan indicating the need for two staff members for bed mobility and transfers due to their non-ambulatory status and increased fall risk. Despite this, the CNA proceeded with the care alone and lowered the side rail at the resident's request, which was against the care plan's instructions. The CNA was unaware of the requirement for two staff members for bed mobility and positioning, despite having signed an acknowledgment form indicating she was educated on the care plans and Care Kardex cards. Interviews with the resident, nursing staff, and the Director of Nurses confirmed that the CNA did not follow the care plan. The CNA admitted to not knowing the resident required two staff members for bed mobility and positioning and stated that she had not been shown where the Care Kardex cards were located. The incident highlighted a failure in communication and adherence to the care plan, resulting in the resident's injury.
Failure to Provide Adequate Assistance and Use of Assistive Devices
Penalty
Summary
The Facility failed to ensure that a resident who required assistance of two staff members for bed mobility and the use of bilateral side rails was provided with the necessary level of staff assistance and required assistive device. On the day of the incident, a CNA, without obtaining assistance from another staff member, put the side rails down and rolled the resident onto their side. As a result, the resident rolled off the bed onto the floor, landing on their right side and immediately complained of pain. The resident was subsequently transferred to the Hospital Emergency Department and diagnosed with acute non-displaced fractures of the right superior and inferior pubic rami. The resident had been admitted to the Facility in May 2019 with diagnoses including general Osteoarthritis and Rheumatoid Arthritis. The resident's care plans and assessments indicated that they were at increased risk for falls, required assistance of two staff members for bed mobility and transfers, and utilized bilateral side rails in bed. Despite these documented needs, the CNA did not follow the care plan and proceeded to provide care without the required assistance, leading to the resident's fall and injury. Interviews with the resident, nursing staff, and the CNA revealed that the CNA was aware of the resident's need for two-person assistance but did not follow the care plan. The CNA claimed that the resident insisted on putting the side rail down, and she complied without seeking additional help. The Director of Nurses confirmed that the CNA failed to follow the care plan and should have requested assistance from another staff member. The incident resulted in the resident experiencing increased pain and being unable to get out of bed since the fall.
Violation of Resident Privacy Due to Unauthorized Video Call
Penalty
Summary
The Facility failed to ensure the privacy of two severely cognitively impaired residents when a Certified Nurse Aide (CNA) used her personal cell phone to participate in a non-work-related live video call while providing care. The incident occurred on 03/14/24, involving Resident #1, who had Parkinson's Disease and neurocognitive disorder with Lewy Bodies, and Resident #2, who had Alzheimer's Disease, anxiety disorder, and aphasia. Both residents were dependent on staff for activities of daily living and mobility, and their Health Care Proxies were activated. The CNA did not obtain consent from the residents or their representatives before including them in the video call, violating their right to privacy and confidentiality as per the Facility's policies and Federal and State laws. During the incident, CNA #1 answered a video call from a family member while assisting with Resident #1 in the shower room. She turned the phone's camera towards Resident #1's face and made comments about the resident's agitation, which were heard by the person on the call. CNA #2, who was present, confirmed that CNA #1 remained on the call during the provision of care. Later, CNA #1 continued the video call while assisting Resident #2 in the bathroom, propping the phone on the sink and potentially exposing Resident #2's personal care to the person on the call. Although CNA #1 claimed the camera was pointed at her back, she admitted that the audio was not obstructed. The Director of Nurses (DON) confirmed that CNA #1's actions violated the Facility's Mobile Device Use Policy and the residents' right to privacy. The internal investigation revealed that CNA #1 had indeed used her personal cell phone in a resident care area and included the residents in a video call without consent. This breach of privacy and confidentiality was against the standard of care provided at the Facility.
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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