Keystone Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Leominster, Massachusetts.
- Location
- 44 Keystone Drive, Leominster, Massachusetts 01453
- CMS Provider Number
- 225355
- Inspections on file
- 33
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Keystone Center during CMS and state inspections, most recent first.
A resident with an indwelling catheter did not receive catheter irrigation as ordered by the physician. Nursing staff failed to clamp the catheter and wait 30 minutes after instilling the acetic acid solution, instead allowing it to drain immediately, contrary to the prescribed procedure. This was confirmed through staff interviews and review of facility policy.
A resident with a G-tube and orders for continuous enteral feeding and scheduled water flushes received incorrect volumes of formula and water when staff placed the formula and water in the wrong pump bags. The error was discovered after a visitor reported the issue, and interviews confirmed that the feeding system had been set up incorrectly, resulting in the resident not receiving nutrition and hydration as prescribed.
A resident was admitted with bilateral nephrostomy tubes, but the facility failed to ensure that licensed nurses had the necessary competencies to provide appropriate care. The facility's assessment indicated capability in handling genitourinary conditions, yet competency evaluations for nurses did not include nephrostomy tube care. Interviews with the ADON and DON confirmed the oversight, and no records were kept of staff education on this care after the resident's admission.
The facility failed to ensure the DON did not serve as Charge Nurse when occupancy exceeded 60 residents. The DON worked as Charge Nurse on multiple occasions due to staffing shortages, interfering with her primary responsibilities. This was confirmed by facility records and interviews with the DON.
A resident was not informed about a new antipsychotic medication, Olanzapine, administered after hospitalization, violating their right to participate in their care plan. The facility's policy requires informed consent and discussion of medication risks and benefits, which was not followed. The resident received the medication for 22 days without prior consent, which was only obtained on the last day.
A resident experienced significant weight loss, but the facility failed to notify the Physician or NP as required by policy. Despite the resident's weight being monitored, the NP was not informed of the weight loss, which was identified by the dietitian, leading to a lack of follow-up actions.
The facility failed to update care plans for two residents after falls and did not hold a care plan meeting for another resident. One resident's care plan lacked fall prevention goals after a fall, while another resident used safety equipment without a physician's order or care plan revision. Additionally, a care plan meeting was not documented for a resident following an MDS assessment.
A resident with GERD and IBS did not receive the correct medication due to a failure in transcribing a verbal order from the physician. The DON received the order to switch from Protonix to Prilosec OTC but did not ensure it was entered into the medical record, resulting in the resident continuing on the previous medication regimen.
A resident with dementia in an LTC facility was not provided with activities that matched their preferences and needs, as outlined in their care plan. Despite assessments indicating a need for afternoon activities, music, and social interaction, the resident was often observed alone and without engagement. Staff attempts to provide 1:1 activities were inadequately documented, leading to a deficiency in meeting the resident's activity needs.
A resident with dysphagia and loose dentures was not provided with necessary interventions during a meal, leading to repeated coughing and gagging. Despite the presence of the ADON, the resident continued to eat without proper supervision and assistance, as outlined in their care plan. Staff interviews revealed a lack of awareness and adherence to the resident's care plan, resulting in a failure to ensure safe eating practices.
A resident with nephrostomy tubes did not receive the required flushing as ordered by the physician, due to the facility's failure to enter the order into the electronic medical record. The resident, who had been performing the flushing at home, expressed concerns about potential obstructions. The Director of Nursing admitted the order was incorrectly entered, leading to the absence of necessary orders in the MAR and TAR.
A facility failed to provide appropriate treatment and services to a resident with mental health needs by not developing an individualized care plan or revising it after the resident expressed suicidal ideation and was hospitalized. The resident, with a history of depression and anxiety, did not receive timely therapy sessions or meet with the social worker upon return. Interviews revealed that the care plan was not updated as required, contributing to the deficiency.
The facility failed to review and address pharmacist recommendations for two residents, one with cognitive impairments and multiple diagnoses, and another receiving various psychotropic medications. The Director of Nursing could not provide evidence of the reviews, indicating non-compliance with the facility's policy.
A resident with depression, anxiety, and alcohol abuse diagnoses was not monitored for adverse effects of antipsychotic medications as required. The facility failed to conduct timely AIMS assessments every three to six months, as per policy, to monitor for tardive dyskinesia. The resident received Olanzapine and Aripiprazole, but no updated AIMS assessment was completed since admission, and no care plan was developed to monitor for side effects. The DON confirmed the oversight.
A resident with cellulitis and other conditions did not have their medicated lotion treatments documented as required. Despite the resident's report of inconsistent application, the facility's TAR lacked signatures for several treatment dates. The DON confirmed the missing documentation, and the ADON later verified that the care was provided but not recorded.
The facility failed to implement proper infection control measures, including not following Enhanced Barrier Precautions for a resident with wounds and a Foley catheter, and not replacing meals for two residents exposed to emesis during dining. Staff acknowledged these oversights, highlighting lapses in infection prevention protocols.
A CNA in an LTC facility was observed sitting with her legs across a resident's lap, encouraging the resident to play with her legs and hair to keep them calm. The resident, who had severe cognitive impairment and a history of challenging behaviors, was not treated with dignity and respect as per their care plan. The incident was witnessed by the Director of Social Services and the DON, who noted the inappropriate nature of the interaction.
A resident with severe cognitive impairment and a history of falls was found using a concave mattress and bed rails without a documented restraint assessment. Despite staff acknowledging the resident's frequent unassisted standing and falls, the facility failed to assess whether these devices restricted the resident's movement, contrary to their policy.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment. A CNA was observed with her legs crossed and extended across the resident's lap, restraining them in their wheelchair. Despite the Director of Nurses recognizing this as a restraint, the incident was not reported to the DPH, as required by the facility's policy.
A facility failed to investigate an alleged restraint incident involving a resident with severe cognitive impairment. A CNA was seen with her legs across the resident's lap, but the facility did not document a formal investigation or determine an outcome, as they did not consider it abuse. The investigation file lacked interviews and a summary, contrary to facility policy.
A facility failed to conduct a Bed Rail Entrapment Assessment for a resident with severe cognitive impairment before using bed rails. The facility's policy requires an evaluation of the resident's sleeping environment and compatibility checks of bed components, but no documentation was found to support that these assessments were completed. The Director of Maintenance confirmed the absence of safety testing documentation after a mattress change, and the DON was unaware of when the bed rails were added.
A resident with severe cognitive impairment was physically abused by a CNA who restrained the resident with his knee and yelled at them during an attempted transfer to bed. The resident's care plan advised against such actions, emphasizing patience and reapproaching if care was refused. The incident was witnessed by two other CNAs, leading to the immediate suspension and termination of the offending CNA.
A facility failed to conduct a Criminal Offender Record Inquiry (CORI) on a CNA before employment, as required by its Abuse Policy. The CNA was employed without a CORI check, which was only performed after an abuse allegation was made against him, leading to his termination. Interviews confirmed the lack of documentation for a CORI check prior to the CNA's employment.
Failure to Follow Physician's Orders for Catheter Irrigation
Penalty
Summary
A deficiency occurred when a resident with an indwelling catheter and multiple diagnoses, including Multiple Sclerosis, Dementia, and neuromuscular dysfunction of the bladder, did not receive catheter care in accordance with the physician's orders. The physician had ordered daily irrigation of the catheter using 30 ml of 0.25% acetic acid solution, with instructions to clamp the catheter for 30 minutes after instillation, then flush with sterile water. However, nursing staff performed the irrigation by instilling the solution and immediately allowing it to drain into the bag, without clamping the catheter or waiting the required 30 minutes before flushing. This deviation from the prescribed procedure was confirmed during interviews with the nurse responsible for the resident's care, who acknowledged not following the specific order to clamp the catheter and wait before flushing. The Assistant Director of Nurses also confirmed that the nurse had not performed the catheter irrigation as ordered. Facility policy on catheter irrigation was available, but the required steps in the physician's order were not followed for this resident.
Incorrect Administration of Enteral Nutrition Due to Feeding Pump Setup Error
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (G-tube) was not provided with appropriate treatment and services as prescribed by the physician. The resident, who had diagnoses including Multiple Sclerosis, Dementia, and G-tube status, had specific physician orders for the administration of enteral formula (Jevity 1.5 at 45 ml/hour) and water flushes (200 cc every four hours). Facility policy required staff to be trained and competent in enteral nutrition administration, including verifying the correct rate and volume for tube feedings and flushes. However, the resident's formula and water flushes were placed in the incorrect enteral pump bags, resulting in the resident receiving incorrect volumes of formula and water. The error was identified after a visitor observed the mistake and notified facility staff. Interviews with nursing staff confirmed that the feeding pump tubing, formula, and water flush had been set up incorrectly, leading to the resident not receiving tube feeding and water flushes as ordered. The Assistant Director of Nursing and the Nursing Supervisor both acknowledged that the system had been set up incorrectly, which resulted in the resident not being administered tube feeding and water flushes according to the physician's orders.
Lack of Competency in Nephrostomy Tube Care
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets to care for a resident with nephrostomy tubes. Resident #372 was admitted with bilateral nephrostomy tubes, a condition that requires specialized care. The facility's assessment indicated that staff could provide care for residents with genitourinary system diseases and special treatments like ostomy care, yet the competency evaluations for Nurses #6, #1, #5, and #4 did not include nephrostomy tube care. The competency evaluations for the nurses showed assessments in various areas such as medication administration, sterile wound care, and tube feeding, but lacked any assessment for nephrostomy tube care. Despite the facility's claim of being able to handle such cases, there was no evidence that the nurses had been evaluated for this specific competency. This oversight was evident as the nurses assigned to care for Resident #372 had not been assessed for their ability to manage nephrostomy tubes. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the competency evaluations did not include nephrostomy tube care. The ADON, who also served as the Staff Development Coordinator, was on vacation during the resident's admission and acknowledged that education on nephrostomy tube care should have been initiated immediately. The DON confirmed that the competency assessments needed to be updated to include nephrostomy tube care, but no records were kept of which staff received the necessary education after the resident's admission.
DON Serving as Charge Nurse Despite High Occupancy
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as the Charge Nurse when the facility had an average daily occupancy of greater than 60 residents. This deficiency was observed on multiple occasions during the Quarter Three Payroll Based Journal (PBJ) Staffing Data Report period and in the four weeks prior to the survey start date. Specifically, the DON was found to have worked as the Charge Nurse on four dates during Quarter Three, including two weekends, and on three additional dates in the weeks leading up to the survey. The facility's daily census reports confirmed that the resident occupancy exceeded 60 on all these occasions. Interviews with the DON revealed that she was called in to work as a Charge Nurse when scheduled nurses did not show up or called out, and replacements could not be found. The DON acknowledged that working as a Charge Nurse interfered with her ability to fulfill her responsibilities as the DON. The facility's records, including Daily Nursing Attendance Reports and the DON's time cards, corroborated the instances where the DON served in dual roles, highlighting a staffing issue that led to the deficiency.
Failure to Inform Resident of New Medication Treatment
Penalty
Summary
The facility failed to inform a resident about a new medication treatment and the associated risks and benefits, violating the resident's right to participate in their plan of care. The resident, who was cognitively intact, was not informed about the administration of Olanzapine, an antipsychotic medication, upon their return from hospitalization. The facility's policy requires that residents and their representatives be involved in medication management and informed about the risks and benefits of psychotropic medications, which was not adhered to in this case. The resident received Olanzapine daily for 22 days without prior informed consent, which was only obtained on the last day of administration. Interviews with the physician and the Director of Nursing revealed that the medication was prescribed and administered without discussing it with the resident, and the consent process was not followed as per the facility's policy. The physician independently decided to discontinue the medication without input from nursing or psychiatric services, further indicating a lack of communication and adherence to protocol.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner (NP) of a significant change in condition for a resident, specifically regarding a significant weight loss. The resident, who was admitted with diagnoses including muscle wasting and atrophy, bipolar disorder, and developmental delay, experienced a weight loss of 11.8% in less than 180 days. The facility's policy required notification of the physician for significant weight changes, but there was no documented evidence that the physician or NP was informed when the dietitian identified the weight loss. The resident's weight was monitored as per physician's orders, with weights recorded on specific dates. However, there was a lack of communication to the NP about the resident's weight loss, which was confirmed during an interview with the NP. The NP stated that typically the Director of Nursing or nursing staff would communicate such changes, but in this case, the weights were not reported, preventing any potential follow-up actions that might have been warranted.
Care Plan Deficiencies and Lack of Documentation
Penalty
Summary
The facility failed to ensure the care plans for two residents were assessed and revised appropriately, and did not hold a care plan meeting for another resident. For one resident, the care plan was not updated with measurable goals for fall prevention after the resident sustained a fall. The resident, who was admitted with diagnoses including encephalopathy, bipolar disorder, schizoaffective disorder, and muscle weakness, was found on the floor after a fall, having hit their head. Despite this incident, the care plan did not reflect an assessment of the fall or any new interventions to prevent future falls. Another resident, admitted with cognitive impairment, depression, insomnia, and muscle weakness, was observed using mattress bolsters and floor mats, but there was no physician's order or care plan revision to include these safety measures. The facility's nurse confirmed that such measures should have been documented and assessed every shift, but this was not done for the resident. Additionally, a third resident, who was cognitively intact, did not have evidence of a care plan meeting following a Minimum Data Set (MDS) assessment. The Director of Social Services acknowledged that there was no documentation of a care plan meeting, which should have included the resident and/or their representative, as well as the interdisciplinary team.
Failure to Transcribe Verbal Medication Order
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident due to a lapse in transcribing a verbal medication order. The Director of Nursing (DON) received a verbal order from the resident's physician to change the medication from Protonix 40 mg twice daily to Prilosec OTC 20 mg daily. However, this order was not transcribed into the resident's medical record, resulting in the resident not receiving the updated medication as prescribed. The resident, who was admitted with diagnoses including Gastro Esophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS), continued to receive the previous medication regimen. The DON acknowledged the oversight, stating that the verbal order was given to another nurse to transcribe, but it was not documented, and the resident did not receive the correct medication. This failure to implement the physician's order was identified during a review of the active physician's orders and confirmed through interviews with the DON.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of a resident diagnosed with dementia, who was admitted in December 2023. The resident was assessed as severely cognitively impaired with a BIMS score of zero. The resident's activity assessment indicated preferences for afternoon activities, reading materials, music, news, social interaction, and favorite activities. However, observations and interviews revealed that these preferences were not adequately addressed. During multiple observations, the resident was found either sleeping in bed or seated alone without any engagement in activities or access to preferred items like a television or radio. The resident's representative expressed concerns about the resident being bored and the staff's inability to keep the resident engaged. The activity care plan noted the resident's dependence on staff for cognitive stimulation and social interaction, yet there was a lack of documented participation in activities from September 6 to September 9, 2024. Interviews with staff, including a CNA and the Activities Director, indicated attempts to engage the resident with 1:1 activities and tools like a fidget board. However, there was insufficient documentation of these activities, and the Activities Director could not provide specifics about a cognitive game reportedly provided on September 10, 2024. The lack of consistent and documented activity engagement highlights the facility's failure to meet the resident's individualized activity needs as outlined in their care plan.
Failure to Ensure Safe Eating Practices for Resident with Dysphagia
Penalty
Summary
The facility failed to provide a safe environment free from accidental hazards for a resident with dysphagia during a meal. The resident, who had a diagnosis of Parkinson's Disease and dysphagia, required continual supervision and assistance with eating, as outlined in their care plan. However, during a breakfast observation, the resident was not provided with necessary interventions such as securing dentures with adhesive, encouraging small bites, and ensuring the resident did not continue eating while coughing. The resident was observed eating scrambled eggs without their dentures being secured, leading to repeated coughing and gagging episodes. Despite the presence of the Assistant Director of Nursing (ADON) in the dining room, the resident continued to eat without the recommended supervision and interventions. The ADON intervened only after the resident's dentures were visibly loose and instructed a Certified Nurses Aide (CNA) to remove them, but did not follow the care plan's instructions to encourage safe eating practices. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. The CNA was unaware of the morning oral care provided to the resident and did not ensure the use of denture adhesive, which was available in the resident's room. The Speech Language Pathologist confirmed the resident's need for continual supervision and specific interventions during meals, which were not implemented during the observed breakfast.
Failure to Provide Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with nephrostomy tubes, as staff did not flush the tubes as ordered by the physician. The facility's policy and professional standards require that nephrostomy tubes be flushed to prevent blockage and infection. However, the resident, who was admitted with diagnoses including malignant neoplasm of the bladder and was under palliative care, reported that the facility staff did not perform the necessary flushing of the nephrostomy tubes. The resident expressed concerns about potential obstructions due to the lack of flushing, which he had been doing twice daily at home. Upon review, it was found that the physician's order to flush the nephrostomy tubes was not entered into the facility's electronic medical record (EMR) upon the resident's admission. The Director of Nursing acknowledged that the order was incorrectly entered, resulting in the absence of the necessary orders in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). This oversight led to the failure to provide the required nephrostomy tube care for the resident.
Failure to Update Care Plan for Resident with Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders, specifically failing to develop an individualized care plan to address the emotional and psychosocial needs of the resident. The resident, who had a history of depression, anxiety, and alcohol abuse, expressed suicidal ideation and was hospitalized. Upon return, the facility did not revise the care plan to incorporate findings from the comprehensive assessment or to include targeted and individualized interventions. The facility's policy required that new onset or changes in behavior be documented and that the care plan be consistent with current standards of practice. However, the care plan for the resident was not updated after the expression of suicidal ideation, hospitalization, and re-admission. The resident reported not meeting with the facility's social worker upon return and only recently starting therapy sessions, indicating a lack of ongoing assessment and monitoring of the resident's emotional and psychosocial needs. Interviews with the Director of Social Services and the Director of Nursing revealed that the care plan was not reviewed or revised as required. The Director of Social Services acknowledged that supportive visits were not documented, and the Director of Nursing confirmed that the care plan should have been updated following the resident's return from the hospital. This lack of documentation and failure to update the care plan contributed to the deficiency in providing appropriate care for the resident.
Failure to Address Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to review and address the Pharmacist Medication Review recommendations for two residents, leading to a deficiency in compliance with their own policies. For one resident, who was admitted with diagnoses including Encephalopathy, Bipolar Disorder, Schizoaffective Disorder, and Muscle Weakness, the facility did not verify or confirm that the pharmacist's recommendations made in October and December 2023 were reviewed or addressed. The Director of Nursing (DON) acknowledged the absence of these recommendations in the resident's record and indicated that they would need to contact the pharmacy to obtain them, as they were not available at the time of the survey. Similarly, for another resident with diagnoses of Depression and Anxiety, the facility did not verify or confirm the review or addressing of pharmacist recommendations made on multiple occasions between September 2023 and May 2024. The resident was cognitively intact and received various psychotropic medications, including antipsychotics, antianxiety, antidepressants, hypnotics, and opioids. The DON was unable to provide evidence of the pharmacy reviews for the specified dates, indicating a failure to adhere to the facility's policy of timely communication and follow-up on pharmacist recommendations.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility did not conduct timely monitoring for adverse consequences and side effects using the Abnormal Involuntary Movement Scale (AIMS) assessment. The facility's policy on psychotropic medication use requires adequate monitoring for efficacy and adverse consequences, including the administration of the AIMS assessment every three to six months to monitor for tardive dyskinesia. However, the medical record review revealed that an updated AIMS assessment had not been completed for the resident since August 2023, despite the resident receiving antipsychotic medications such as Olanzapine and Aripiprazole. The resident, who was admitted to the facility with diagnoses including depression, anxiety, and alcohol abuse, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident received Olanzapine and Aripiprazole as prescribed, but the facility failed to develop a plan of care to monitor for adverse consequences and side effects related to the antipsychotic medication use. During an interview, the Director of Nursing acknowledged that an AIMS assessment should have been completed every six months and confirmed that it had not been done for this resident.
Failure to Document Medicated Lotion Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of medicated lotion treatments. The resident, who was admitted with conditions including the need for assistance with personal care, adult failure to thrive, and cellulitis of the lower extremities, was prescribed Lac-Hydrin Twelve External Lotion to be applied twice daily. However, the Treatment Administration Record (TAR) did not reflect the administration of this treatment on several occasions, as observed by surveyors. During interviews and observations, the resident reported that the medicated lotion was not consistently applied as ordered. The Director of Nursing confirmed that the TAR lacked signatures for the specified dates, indicating that the treatments were not documented as provided. The Assistant Director of Nurses later confirmed that the care was given, but the nurses had forgotten to sign off on the TAR, which was against the facility's policy and professional standards.
Infection Control Deficiencies in Resident Care and Dining
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by two specific deficiencies. Firstly, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with wounds and a Foley catheter. Despite physician orders requiring the use of gown and gloves during high-contact activities such as wound care, a nurse was observed performing wound care without wearing a gown, thereby not following the prescribed EBP. The nurse acknowledged the oversight, and the Infection Preventionist confirmed that the EBP should have been followed due to the resident's high risk of infection. Secondly, the facility did not adequately protect two residents from potential infection risk during a dining incident. When another resident expelled emesis at the same table, the staff removed the soiled items and disinfected the area but did not offer to replace the meals of the two residents seated nearby. Although the Director of Nursing offered to move the residents to another table, the meals were not replaced, which was acknowledged as an oversight by both the Infection Preventionist and the Director of Nursing.
Inappropriate Interaction with Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment was treated with dignity and respect. On the specified date, a CNA was observed sitting next to the resident in a wheelchair with her legs outstretched and crossed over the resident's lap. The CNA encouraged the resident to play with her legs and hair as a means to keep the resident calm. This action was witnessed by the Director of Social Services and the Director of Nurses, who both noted the inappropriate nature of the interaction. The resident, who had been admitted to the facility with diagnoses including Parkinson's Disease, dementia, and schizoaffective disorder, was known to exhibit behaviors such as yelling, hitting, and resisting staff. The resident's care plan suggested distraction with tasks or activities as a strategy to manage these behaviors. However, the CNA's method of distraction was deemed undignified and potentially inappropriate, as it involved physical contact that could be misconstrued. The incident was reported by multiple staff members, and the CNA acknowledged her actions, stating she was trying to keep the resident occupied.
Failure to Assess Restraint Use for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment was free from the use of physical restraints. The resident, who had diagnoses including Parkinson's disease, dementia, and a history of falls, was observed lying on a concave/perimeter mattress with bed rails in the upright position. Despite the facility's policy requiring a restraint assessment to determine if such devices restricted the resident's freedom of movement, no documentation was found to support that an assessment had been completed for the bed rails or the concave mattress. Interviews with staff revealed that the resident frequently attempted to stand unassisted and had a history of falls, yet the necessary assessments to determine if the mattress and bed rails were acting as restraints were not conducted. The Director of Nurses (DON) acknowledged that a restraint assessment should have been completed but could not provide documentation to support that it had been done for the bed rails or the concave mattress. The DON stated that the concave mattress was intended to prevent falls and remind the resident to stay in bed, but there was no evidence of a completed assessment to confirm whether these devices restricted the resident's ability to get out of bed. Despite the DON's claim that the resident could easily get up with the devices in place, the lack of documented assessments indicates a failure to comply with the facility's policy on restraint use.
Failure to Report Alleged Abuse Involving Restraint
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment who had been attempting to stand unassisted. The incident involved a Certified Nurse Aide (CNA) who was observed by the Director of Social Services and the Director of Nurses with her legs crossed and extended across the resident's lap, effectively restraining the resident in their wheelchair. Despite the Director of Nurses acknowledging the situation as a form of restraint, the incident was not reported to the Massachusetts Department of Public Health (DPH) as required by the facility's policy. The facility's policy mandates that all reports of resident abuse, including the use of restraints, be reported to local, state, and federal agencies. However, the Director of Nurses did not consider the incident to be an abuse allegation and therefore did not report it. The Administrator also did not report the incident, citing the resident's good spirits and the belief that the CNA's legs were not actually on the resident. This oversight resulted in a failure to comply with the reporting requirements outlined in the facility's policy.
Failure to Investigate Alleged Restraint Incident
Penalty
Summary
The facility failed to conduct a thorough investigation after being made aware of an allegation of a possible restraint involving a resident with severe cognitive impairment. The resident, who was dependent on staff for care due to conditions such as Parkinson's disease and dementia, was allegedly restrained by a CNA who placed her legs across the resident's lap. Despite the Director of Social Services and the Director of Nursing witnessing the incident and expressing concern, the facility did not document a formal investigation or determine an outcome, as they did not consider the incident to be abuse. The facility's investigation file lacked documentation of interviews with the resident or other residents who might have witnessed the incident. Additionally, there was no investigation summary or evidence of a completed investigation. The Director of Nursing and the Administrator both acknowledged that no formal investigation was conducted, as they did not view the incident as an allegation of abuse. This lack of action and documentation is contrary to the facility's policy, which requires thorough investigation and reporting of all allegations of abuse or neglect.
Failure to Conduct Bed Rail Entrapment Assessment
Penalty
Summary
The facility failed to complete a Bed Rail Entrapment Assessment for a resident with severe cognitive impairment before using two quarter rails in the upright position. The facility's policy requires an interdisciplinary team evaluation of the resident's sleeping environment and a compatibility check of bed frames, mattresses, and bed rails. Despite these requirements, there was no documentation to support that the necessary assessment was conducted for the resident, who had diagnoses including Parkinson's Disease, dementia, and a history of falling. The resident's care plan indicated the use of two quarter side rails for mobility and transfers, but the facility did not document a risk assessment for entrapment. During an observation, the Director of Maintenance confirmed the absence of documentation for safety testing of the bed rails after a concave mattress was added to the resident's bed. The only available test results were from before the mattress change. The Director of Nurses was unaware of when the bed rails were added and acknowledged that they should have been tested with both the previous and new mattresses. This oversight indicates a failure to adhere to the facility's policy and ensure the resident's safety.
Resident Subjected to Physical Abuse by CNA
Penalty
Summary
The deficiency involved a resident with severe cognitive impairment who was subjected to physical abuse and mental anguish by a Certified Nurse Aide (CNA) at the facility. The incident occurred when the resident, who was dependent on staff for care, refused to transfer to bed. In response, CNA #1 physically restrained the resident by placing his knee on the resident's lap and hand, despite the resident's protests that he was being hurt. This action was witnessed by two other CNAs, who reported that CNA #1 was also yelling at the resident and asserting authority by claiming to be the 'captain.' The facility's policies clearly state that residents have the right to be free from abuse, including physical restraint not required to treat medical symptoms. The resident's care plan indicated that staff should avoid invading personal space, use a calm voice, and reapproach if the resident refused care. However, CNA #1 did not adhere to these guidelines and instead used excessive force and verbal aggression, leading to the resident's distress. The incident was reported to the Nursing Supervisor, who took immediate action by suspending CNA #1 and contacting the police. The resident involved had a history of Alzheimer's Disease, depression, and paranoid personality disorder, which contributed to his/her cognitive impairment and potential for combative behavior. Despite this, the facility's policies and the resident's care plan emphasized the importance of patience and reapproaching the resident later if care was refused. The failure to follow these protocols resulted in the substantiated allegation of abuse, as confirmed by the facility's investigation and the statements of the involved staff members.
Failure to Conduct CORI Check on CNA Prior to Employment
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not conducting a Criminal Offender Record Inquiry (CORI) on a Certified Nurse Aide (CNA) prior to his employment. According to the facility's policy, background checks are required to prevent abuse, neglect, exploitation, and misappropriation of resident property. However, the CNA in question was employed without a CORI check, which was only conducted after an abuse allegation was made against him. Interviews with the Director of Human Resources and the Administrator confirmed the absence of documentation supporting a CORI check for the CNA before his employment. The Director of HR acknowledged that the CORI was conducted only after the abuse allegation surfaced, leading to the CNA's termination. This oversight indicates a failure in the facility's process to ensure the safety and protection of its residents by not following established protocols for employee background checks.
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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