Lanessa Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, Massachusetts.
- Location
- 751 School Street, Webster, Massachusetts 01570
- CMS Provider Number
- 225395
- Inspections on file
- 32
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lanessa Extended Care during CMS and state inspections, most recent first.
A resident with vascular dementia, generalized anxiety disorder, moderate cognitive impairment (BIMS 9), and documented wandering and exit‑seeking behaviors, who lived on a secured unit with alarmed exits and was assessed as at risk for elopement, exited the unit through an alarmed exterior door during the night shift. Staff heard an alarm but initially assumed it was triggered by a nurse leaving through an interior lobby door, and one CNA did not hear it at first due to a loud TV near his documentation area. After realizing the alarm was from the exterior door, staff searched the unit, found the resident missing, activated the missing resident protocol, and contacted 911. The resident was found by police at the end of the block, evaluated in the ED with no hypothermia, and returned. The DON later stated that the secured unit is for exit‑seeking residents, that staff had mistaken the alarm source, and that the exterior door alarm was not loud enough and shared the same sound as the lobby door alarm.
A resident with multiple health conditions developed a stage 3 pressure injury on the wrist after being admitted with a right arm immobilizer. Although wound treatment orders were obtained, nursing staff did not create or update a care plan with interventions, goals, or outcomes to address the new wound, as required by facility policy. Interviews confirmed that the care plan was not amended following the change in condition.
A resident with multiple comorbidities and a recent right humerus fracture experienced significant delays in follow-up care due to the facility's failure to arrange appropriate wheelchair-accessible transportation. Multiple scheduled appointments with an orthopedic surgeon were missed or canceled because transportation requests did not specify the need for a wheelchair van, resulting in the resident not being evaluated for over a month after hospital discharge.
The facility failed to maintain accurate records of controlled substance medications on the Elmwood and Windsor Units. Controlled substances were removed from medication carts and stored in the DON's office without proper documentation of destruction. The DON and CNS confirmed that medications had not been destroyed for six months, and there was no disposal record in place. Observations revealed five large bags containing 80 different controlled substances, including opioids and antianxiety medications, stored in the DON's office.
The facility failed to maintain an effective pest control program, resulting in the presence of pests in the Windsor Unit and Main Dining Room. The facility's agreement required 12 pest control services per year, but only 11 were provided in 2024. Observations revealed small, winged insects in various areas, including a resident's room and the Main Kitchen. Despite identifying fruit flies in November, no follow-up actions were taken, and no pest control services were obtained after October.
The facility failed to accurately complete MDS assessments for several residents, leading to deficiencies in documenting their care. A resident was not coded for hospice services, while others were not accurately coded for receiving various medications, including opioids, psychotropics, and antidepressants. These inaccuracies were acknowledged by the MDS nurses, highlighting the need for accurate coding to ensure proper care planning.
A resident with gout experienced increased pain due to a transcription error that resulted in receiving Allopurinol once daily instead of the prescribed twice daily. The error occurred because the new order was not accurately transcribed to the January MAR, and the double-check system failed.
The facility failed to provide pureed chicken to residents with a physician's order for a pureed diet. Observations revealed that the chicken served was ground instead of pureed, which is unsuitable for residents with dysphagia. Staff interviews confirmed the oversight, as the chicken's consistency was not checked before serving. This affected residents requiring pureed textured foods, indicating a lapse in following dietary guidelines.
The facility failed to maintain sanitary conditions and proper food safety practices in the kitchen and dining areas. A container of Thick-It was found contaminated, and meat lasagna was served at unsafe temperatures. Additionally, the kitchen and dining areas were unsanitary, with unclean equipment and improper temperature maintenance in refrigerators, posing foodborne illness risks.
A facility failed to obtain informed consent from a resident's Health Care Proxy before administering Ativan, a psychotropic medication, for anxiety. Despite the facility's policy requiring consent, the medication was given without it, as confirmed by staff interviews. The resident had diagnoses including Idiopathic Gout, Chronic Kidney Disease Stage 3B, and Major Depressive Disorder.
A facility failed to assess a resident for the appropriateness of self-administering Benadryl cream, as required by their policy. Despite the resident being cognitively intact, no evaluation was conducted before the medication was left at the bedside. The oversight was confirmed by staff interviews, highlighting a lapse in following the facility's procedures for self-medication assessments.
The facility failed to address and document responses to Resident Council grievances about insufficient staffing on the 11:00 P.M. to 7:00 A.M. shift. Despite concerns being raised in meetings, there was no evidence of a formal response or rationale provided by the administration. Staffing records confirmed shortages, affecting resident care, with delays in assistance reported.
The facility failed to accurately execute Advance Directives for two residents, leading to deficiencies in the handling of MOLST forms. One resident's MOLST form was signed by the HCP before the resident was deemed incapacitated, and another resident's MOLST form lacked validation of the HCP's authority. These oversights were identified during a surveyor's review.
The facility failed to properly issue the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for three residents. The NOMNCs lacked provider contact information and were not delivered in the required timeframe. Additionally, the SNF ABN forms were not signed by the responsible parties, indicating a failure to confirm receipt and understanding of the notices.
A resident's wheelchair was found visibly soiled on multiple occasions, with staff acknowledging the lack of cleaning due to staff illness and absence of a specific cleaning policy. The resident, who was severely cognitively impaired and dependent on the wheelchair, did not receive the necessary maintenance to ensure a clean and homelike environment.
The facility failed to schedule a urology appointment for a resident with a kidney stone and did not implement a pulmonary consultation for another resident with COPD symptoms. Additionally, the facility did not follow physician orders for weight monitoring for the latter resident, leading to non-compliance with the care plan.
A resident with nicotine dependence and dementia was left unsupervised during smoking activities, despite requiring routine supervision for safety. The facility's policy required staff supervision during smoking, but observations showed the resident was left alone on multiple occasions, contrary to the facility's expectations.
A facility failed to reassess and update the care plan for a resident with an indwelling urinary catheter upon re-admission from the hospital. The resident, with severe cognitive impairment and multiple diagnoses, returned with a size 24 Fr catheter, but the physician's order indicated a size 16 Fr. No re-admission or catheter assessment was completed, leading to a deficiency in care.
The facility failed to maintain sufficient nursing staff on the Elmwood unit during the night shift, leading to unmet resident needs. Despite the facility's assessment indicating a need for 3.58 hours of direct care per patient per day, staffing levels were inadequate, particularly for residents with advanced cognitive loss. Residents reported delays in receiving assistance, and staff confirmed frequent no-call/no-shows and difficulties in finding replacements, resulting in only one CNA being available on certain shifts.
The facility failed to ensure that a CNA demonstrated the necessary competencies for resident care, as CNA #3 did not complete the required annual competency evaluation for 2024. The Facility Assessment Tool outlined the need for in-service training, but the CNA's record lacked evidence of a completed evaluation. The Administrator could not provide documentation or a policy on CNA competency evaluations.
Two residents with depression and anxiety diagnoses did not receive necessary follow-up behavioral health services as recommended by healthcare providers. Despite being cognitively intact and exhibiting symptoms such as verbal outbursts and rejection of care, the facility failed to ensure timely psychiatric consultations, leading to deficiencies in their mental and psychosocial well-being.
A facility failed to obtain proper consent for psychotropic medications for a resident with cognitive impairment and multiple diagnoses, including PTSD and bipolar disorder. The consent for Trazodone and Buspirone was signed by another resident's HCP, not the appropriate one, contrary to facility policy. This was confirmed during interviews with staff.
A resident at risk for weight loss experienced significant weight fluctuations due to incomplete meal intake documentation by CNAs. Despite the facility's policy requiring accurate documentation, many meal entries were left blank over several months. Interviews confirmed that CNAs were expected to document meal intakes, but this was not consistently done, leading to a lack of accurate records to support care decisions.
The facility failed to maintain infection control practices for three residents, leading to potential contamination and infection risks. A resident's urinary drainage bags were improperly managed, another resident was not assisted with hand hygiene before eating, and Enhanced Barrier Precautions were not followed during a bolus feeding procedure. These deficiencies were observed and confirmed through staff interviews.
The facility did not post complete daily nursing staff data, omitting the total number and actual hours worked by RNs, LPNs, and CNAs, as well as the resident census. The Receptionist and Scheduler were unaware of the requirement to include this information.
A resident with ESRD and Dementia was admitted to hospice, necessitating a Significant Change in Status Assessment (SCSA). The facility failed to complete the SCSA within the required 14-day period, finalizing it 20 days after the significant change was determined. The MDS Nurse confirmed the delay, highlighting the need for timely assessments to meet resident needs.
The facility failed to protect two residents from involuntary seclusion when a CNA tied their room door shut with a plastic bag to prevent one resident from wandering. The incident occurred during a short-staffed evening shift, leaving the residents confined to their room for approximately two hours. The facility's investigation confirmed the CNA's actions and the violation of the facility's policy on abuse, neglect, and exploitation.
The facility failed to ensure staff followed their Abuse Policy by not immediately reporting an incident where a bedroom door was tied shut, involuntarily confining two residents. The incident was discovered two days later by the DON, placing other residents at risk for abuse.
The Facility failed to report an allegation of involuntary seclusion to the DPH within the required two-hour timeframe. The incident, where a door was tied shut to keep a resident safe, was discovered on 01/15/24 but not reported until more than ten hours later. The Facility's policy mandates that any incident involving abuse must be reported within two hours.
A resident with dementia and known exit-seeking behaviors eloped from the Facility without staff knowledge. The resident was found by police four miles away and was transported to the hospital for cold exposure. Staff failed to provide adequate supervision and did not follow the Facility's elopement policy.
The facility failed to provide sufficient nursing staff, resulting in a resident wandering off a locked unit and another resident being involuntarily secluded. The incidents occurred due to understaffing, with only two CNAs and one nurse available to care for 40 residents, leading to inadequate supervision and safety measures.
Elopement of High-Risk Resident Due to Inadequate Response to Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, hazard‑free environment for a resident with known elopement risk, resulting in an elopement from a secured unit. The resident, who had vascular dementia, generalized anxiety disorder, and was moderately cognitively impaired with a BIMS score of 9, had documented behaviors of wandering, exit seeking, and occasional resistance to care. The resident resided on a secured unit with alarms on all exit doors and had been assessed as at risk for elopement and wandering on formal Elopement and Wandering Risk Assessments, as well as on the MDS, which documented wandering behavior on four to six days during the seven‑day look‑back period. The facility’s own elopement policy defined elopement as a resident who is not capable of protecting themselves from harm leaving the facility unsupervised and unnoticed. On the night of the incident, during the 11:00 P.M. to 7:00 A.M. shift, the resident exited the secured unit through an alarmed exterior door at approximately 2:10 A.M. Staff on duty, including a nurse and two CNAs, heard an alarm but initially assumed it was triggered by the nurse leaving the unit through the interior door to the lobby to obtain supplies, rather than the exterior exit door. One CNA reported that he did not initially hear the alarm because a loud television was on near where he was documenting, and only heard it once he moved closer to the nurses’ station. The other CNA stated she heard an alarm around that time and believed it was the lobby door alarm associated with the nurse’s departure, and only upon leaving a resident room did she realize the alarm was coming from the exterior exit door. After staff recognized that the alarm was from the exterior door, they conducted a search of the unit and discovered the resident was missing. A facility‑wide missing resident protocol (Dr. Hunt) was initiated, 911 was called, and staff searched outside and in the parking lot. The resident was ultimately located off facility premises at the end of the block by police, with a staff member present. The resident was transported to the hospital ED, where evaluation determined there were no signs of hypothermia, and the resident was later returned to the facility. The DON stated that the secured unit is intended for residents with exit‑seeking behaviors and acknowledged that staff had mistaken the alarm for the lobby door alarm and that the exterior door alarm was not loud enough to be heard throughout the unit, while both doors shared the same alarm sound.
Failure to Develop and Implement Care Plan for Pressure Injury
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan to address a new pressure injury for a resident with multiple medical conditions, including dementia, chronic kidney disease, anemia, and a recent right humerus fracture. The resident was admitted with a right arm immobilizer following a fall and subsequently developed a stage 3 pressure injury on the right wrist, as documented in the medical record and confirmed by an orthopedic consult. Although treatment orders for the pressure injury were obtained, there was no evidence in the medical record that a care plan with specific interventions, treatment goals, and outcomes was created or implemented to address the wound care needs. Facility policy requires individualized care plans based on comprehensive assessments and mandates updates to care plans following significant changes in a resident's condition. Despite these requirements, interviews with facility staff, including the Unit Manager and DON, confirmed that the care plan was not updated to reflect the new pressure injury. The lack of documentation and failure to amend the care plan after the development of the pressure injury constituted a deficiency in meeting the resident's wound care needs.
Failure to Arrange Timely Transportation for Post-Fracture Follow-Up
Penalty
Summary
A resident with dementia, chronic kidney disease, anemia, and a recent right distal humerus fracture was admitted to the facility and required a follow-up appointment with an orthopedic surgeon one week after discharge from the hospital. The hospital discharge summary specified the need for this timely follow-up to evaluate the resident's candidacy for open reduction surgery. However, the facility failed to ensure the resident was transported to the scheduled appointments due to repeated transportation issues, including the transportation company sending an inappropriate vehicle and late arrivals, resulting in multiple cancellations. Review of transportation request forms revealed that the facility did not specify the need for a wheelchair van, which contributed to the transportation problems. As a result, the resident experienced a delay of over a month before being evaluated by the orthopedic surgeon, contrary to the discharge instructions and medical needs. Interviews with facility staff confirmed ongoing transportation issues and acknowledged that the resident was not provided with the necessary services to attend critical follow-up appointments.
Failure to Maintain Accurate Records of Controlled Substance Medications
Penalty
Summary
The facility failed to maintain accurate records of controlled substance medications management and reconciliation for four locked medication carts on the Elmwood and Windsor Units. The facility's policy requires that controlled substances be handled, stored, disposed of, and recorded in accordance with federal and state laws. However, the surveyor found discrepancies in the documentation of controlled substances that had been removed from the medication carts and stored in the Director of Nursing's (DON) office awaiting destruction. The records did not indicate that these medications had been destroyed, despite being signed out by staff members. During observations, the surveyor noted that narcotic medications had been removed from the controlled substance medication books on both units, with no documentation of their destruction. The DON confirmed that the medications had been removed for destruction and were kept under double lock and key in her office, but she was unsure of how long they had been there. The Clinical Nurse Specialist (CNS) also acknowledged that the medications had not been destroyed for six months, and there was no record of the medications that had been removed from the nurses' medication carts. Further investigation revealed that five large bags containing a total of 80 different controlled substance medications were stored in the DON's office. These included various opioid pain medications, antianxiety medications, and sedatives for multiple residents. The CNS admitted that the facility did not have a controlled substance medication disposal record in place, which should have included details such as the dates of removal, the amount of medication removed per resident, the resident's name, and the type of medication removed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in the Windsor Unit and the Main Dining Room. The facility's Pest Control Services Agreement required inspection and treatment for pests at least 12 times per year, but only 11 services were provided in 2024. Additionally, the facility did not obtain pest control services when staff and residents identified fruit flies in the Main Dining Room and Windsor Unit. The last pest control service was conducted on 10/29/24, specifically for fruit fly prevention in the kitchen and dishwasher areas. Observations by surveyors revealed the presence of small, winged insects in various areas, including Resident #25's room and the Main Kitchen. Interviews with the Food Service Director and Cook indicated a previous issue with fruit flies, but no current problems were noted by the staff. However, the Administrator acknowledged observing fruit flies in November 2024 and recorded these observations in the Pest Control Log. Despite this, no follow-up actions were taken to address the sightings, and no pest control services were obtained after the last visit in October 2024.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of their care. Resident #82, who was admitted with dementia and end-stage renal disease, was not coded for receiving hospice services on their Significant Change in Status Assessment (SCSA), despite being admitted to hospice services prior to the assessment date. This oversight was acknowledged by MDS Nurse #1, who confirmed that the assessment should have reflected the hospice services provided. Resident #235, admitted with conditions including delirium and traumatic brain injury, was not accurately coded for receiving multiple medications, including anticoagulants, antidepressants, antipsychotics, and antianxiety medications, during the observation period for the MDS assessment. MDS Nurse #2 confirmed the inaccuracy, noting that the resident's medication administration records indicated the use of these medications, which should have been reflected in the assessment. Additional inaccuracies were found in the MDS assessments for Residents #38, #54, and #51. Resident #38 was not coded for receiving opioid medication, despite being administered Tramadol as prescribed. Resident #54's assessment failed to indicate the use of psychotropic medications, which were part of the resident's treatment plan. Similarly, Resident #51's assessment did not reflect the use of antidepressant medication, despite the resident being prescribed and administered Cymbalta. These errors were acknowledged by the respective MDS nurses, who noted the need for accurate coding to ensure proper care planning.
Medication Transcription Error Leads to Inadequate Gout Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an order for Allopurinol, a medication used to prevent gout pain, was not accurately transcribed to a new monthly Medication Administration Record (MAR). The resident, who was admitted with diagnoses including Idiopathic Gout and Major Depressive Disorder, had a physician's order to increase Allopurinol to 100 mg twice a day due to increased gout pain. However, this order was not accurately transcribed to the January 2025 MAR, resulting in the resident receiving the medication only once a day. The error was identified during an interview with the resident, who reported experiencing gout pain. The Unit Manager acknowledged that the new order was posted on the December 2024 MAR but not on the January 2025 MAR due to a failure in the double-check system for editing. The Clinical Nurse Specialist confirmed that the error occurred because of a transcription mistake during the end-of-month editing process. The responsibility for double-checking the accuracy of the transcription was not fulfilled, leading to the medication error.
Failure to Provide Pureed Diet as Ordered
Penalty
Summary
The facility failed to provide pureed chicken to four residents who had a physician's order for a pureed texture diet. The deficiency was identified during a survey when it was observed that the chicken served at lunch was not of the required pureed consistency. Instead, the chicken was ground, which is not suitable for residents with moderate to severe dysphagia who require a smooth, pudding-like consistency to safely consume their meals. The facility's US Foods Diet Guide and job descriptions for dining services staff clearly outlined the need to follow therapeutic diet cards and prepare food according to specific dietary requirements, which was not adhered to in this instance. During interviews, the Dietary Aide and Food Service Director (FSD) acknowledged that the chicken was not prepared correctly and should have been checked before being served. The Cook admitted to not verifying the consistency of the pureed chicken before it was delivered to the residents. The Speech Therapist confirmed that the pureed food should have been of a moist, baby food-like consistency, which was not achieved. This oversight affected four residents who required pureed textured foods, highlighting a lapse in the facility's adherence to dietary guidelines and procedures.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, leading to potential foodborne illness risks. During an inspection, a large container of Thick-It, a thickening agent used for residents with swallowing difficulties, was found uncovered and contaminated with cardboard debris. The Food Service Director (FSD) acknowledged the contamination but had not yet discarded the product, indicating a lapse in immediate corrective action. Additionally, the facility did not ensure that food was stored and served at safe temperatures. The meat lasagna served as the main entree for lunch was recorded at 134°F, below the required 135-140°F range. Despite this, the lasagna was served to residents, and the FSD admitted that the dietary aide should have returned it for reheating. This oversight posed a concern for food safety, as serving food at improper temperatures can lead to foodborne illnesses. The facility's kitchen and dining areas were also found to be in unsanitary conditions. Observations included crumbs and dried substances in the freezer and refrigerator, unclean movable carts, a broken ice machine vent with dust accumulation, and a walk-in refrigerator with standing liquid. The FSD admitted to the lack of a cleaning schedule or logs, which contributed to the unsanitary conditions. Furthermore, the dishwasher was not reaching the required temperature for sanitization, and the refrigerator in the Windsor Unit was not maintaining the correct temperature, leading to potential spoilage of stored food items.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from the invoked Health Care Proxy (HCP) for the administration of psychotropic medication to a resident. The resident, who was admitted with diagnoses including Idiopathic Gout, Chronic Kidney Disease Stage 3B, and Major Depressive Disorder, was prescribed Ativan for anxiety or agitation. Despite the facility's policy requiring informed written consent from the resident's HCP before administering psychotropic medications, the consent was not obtained prior to administering Ativan on November 9, 2024. Interviews with facility staff, including a Unit Manager and the Director of Nursing, confirmed that the necessary consent was not present in the resident's medical record. The facility's policy mandates that informed consent should include details about the purpose, dosage, and potential effects of the medication, and should be documented in the resident's medical record. However, this procedure was not followed, resulting in the administration of Ativan without the required consent from the resident's HCP.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the clinical appropriateness to self-administer medications, specifically Benadryl cream, which was ordered to be left at the resident's bedside. The facility's policy requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications, along with documentation of the assessment and communication with the resident or responsible party. However, no such evaluation was completed for the resident, despite the resident being cognitively intact as indicated by a perfect score on the Brief Interview of Mental Status (BIMS). The deficiency was identified during a review of the resident's clinical record, which lacked evidence of an assessment for self-administration of the Benadryl cream. Interviews with the Unit Manager and Clinical Nurse Specialist confirmed that an evaluation should have been conducted before the medication was left at the resident's bedside, but this step was overlooked. The oversight occurred even though the facility's policy clearly outlines the need for such assessments to ensure the safety and appropriateness of self-medication.
Failure to Address Resident Council Grievances on Staffing Levels
Penalty
Summary
The facility failed to adequately address and document responses to grievances related to staffing levels on the 11:00 P.M. to 7:00 A.M. shift, as reported by the Resident Council. On two occasions, the Resident Council raised concerns about insufficient staffing during this shift, which affected the timeliness of care, such as changing and cleaning residents. Despite these grievances being documented in Resident Council meetings, there was no evidence of a formal response or rationale provided by the facility administration, as required by their grievance policy. The facility's grievance policy mandates prompt efforts to resolve grievances, including appointing a grievance officer to oversee the process and issuing written decisions if requested. However, the facility did not adhere to these procedures. The Activities Director recalled completing a Resident Council Concern Form regarding the staffing issue on December 18, 2024, but was unable to locate it. Additionally, the facility's response to the January 21, 2025, grievance was incomplete, lacking a documented rationale for the response. Interviews with residents and staff revealed ongoing issues with staffing during the night shift, with residents experiencing delays in receiving assistance. The facility's staffing records confirmed that staffing levels were below the planned number of CNAs for the 11:00 P.M. to 7:00 A.M. shift on several occasions. The Clinical Nurse Specialist acknowledged the staffing shortages and the need for more CNAs, particularly on the Elmwood unit, which has residents with more acute needs. Despite these acknowledgments, the facility did not provide evidence of addressing the staffing concerns raised by the Resident Council.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for two residents, leading to deficiencies in the handling of MOLST forms. For one resident, the MOLST form was signed by the Health Care Proxy (HCP) before the resident was deemed incapacitated by a physician, rendering the form invalid. The facility did not re-address the MOLST form with the HCP after the resident's admission, and this oversight was only identified when brought to the facility's attention by a surveyor. The resident had been admitted with diagnoses including toxic encephalopathy and seizure disorder. For another resident, the MOLST form was signed by the HCP prior to the resident's admission, without evidence of a HCP activation form or a physician's order to validate the HCP's authority. The facility failed to complete a new MOLST form with the resident, who maintained the capacity for informed medical decision-making. This deficiency was also identified during the surveyor's review, highlighting a lapse in the facility's adherence to its policy for managing MOLST forms.
Failure to Properly Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly issue the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for three residents. For Resident #483, the facility did not provide the NOMNC with the required provider contact information above the title of the form and failed to deliver the notice two days prior to the resident's discharge. The resident signed the NOMNC on the same day as discharge, which was not in compliance with the guidelines. For Resident #63, the facility did not include provider contact information on the NOMNC and failed to provide a paper copy to the responsible party. The NOMNC was emailed, but not mailed, and the SNF ABN form was not signed by the responsible party, indicating a lack of confirmation that the notice was received and understood. Similarly, for Resident #34, the NOMNC lacked provider contact information, and the form was emailed but not mailed to the responsible party. The SNF ABN form also remained unsigned, failing to confirm receipt and understanding by the responsible party. The social worker acknowledged the oversight in completing the provider information on the NOMNC forms and the failure to provide paper copies to the responsible parties. The social worker also admitted to not obtaining signatures on the SNF ABN forms, which are necessary to confirm that the notices were received and understood. These deficiencies indicate a failure to adhere to the CMS guidelines for issuing NOMNC and SNF ABN forms, resulting in non-compliance with the required procedures.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident who was dependent on a wheelchair for mobility. The resident's wheelchair was observed on multiple occasions to be visibly soiled with a white splattered substance and dried brown debris on the armrests. Despite the resident's severe cognitive impairment and reliance on the wheelchair, the necessary cleaning was not performed, compromising the resident's environment. Interviews with staff revealed that the cleaning of wheelchairs was supposed to be conducted weekly by housekeeping, but this was not done due to staff illness and lack of replacement staff. The Certified Nurses Aide (CNA) assigned to the resident acknowledged the wheelchair was dirty and admitted to not contacting housekeeping for cleaning during his shift. The Housekeeping Director confirmed the lapse in cleaning and was unable to provide evidence of the wheelchair being cleaned in the past 30 days. The facility lacked a specific policy for wheelchair cleaning, although the Administrator stated it should occur every two weeks or as needed.
Failure to Schedule Appointments and Monitor Weights
Penalty
Summary
The facility failed to provide care and services that met professional standards of practice for two residents. For one resident, who was admitted with a diagnosis of a kidney stone and related infection, the facility did not schedule a necessary follow-up appointment with a urologist as recommended in the hospital discharge summary. Despite the nurse's admission progress notes indicating the need for this appointment, it was not scheduled, and the oversight was confirmed during an interview with a nurse. Another resident, who was cognitively intact and had a history of chronic conditions including COPD, did not receive a pulmonary consultation as ordered by the nurse practitioner. The resident had been experiencing a chronic cough, and the nurse practitioner had recommended a pulmonary consult to evaluate the possibility of COPD. However, there was no evidence in the clinical record that this consultation was ever scheduled or completed. Additionally, the facility failed to implement physician orders for weight monitoring for the same resident. Despite orders for weekly weights in December and daily weights in January, the resident's weights were not consistently recorded in the medical record. Interviews with the Director of Nursing and the Clinical Nurse Specialist revealed a lack of awareness and follow-through regarding the physician's orders for weight monitoring, resulting in non-compliance with the prescribed care plan.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
The facility failed to provide a smoking environment free of accidental hazards for a resident who required supervision during smoking activities. The resident, diagnosed with nicotine dependence and dementia, was assessed as needing routine supervision during scheduled smoking times to ensure safety. The facility's policy mandated that residents who smoke be evaluated for their ability to do so safely and that smoking occur under staff supervision. However, observations revealed that the resident was left unsupervised while smoking on multiple occasions. On one occasion, the smoking supervisor left the designated smoking area to assist another resident, leaving the resident unsupervised while smoking. On another occasion, the resident was observed smoking without any staff present, despite the smoking supervisor being assigned to supervise at that time. Interviews with the smoking supervisor and facility administrators confirmed that the expectation was for residents to be supervised at all times during smoking to prevent accidents, which was not adhered to in these instances.
Failure to Reassess and Update Catheter Care Plan
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency. Upon the resident's re-admission from the hospital, where they were treated for catheter-associated complications, the facility did not reassess the resident's catheter status. There was no physician order obtained for the current catheter size, and the resident's care plan was not updated to reflect the correct catheter size. The resident, who was severely cognitively impaired and required assistance for perineal hygiene, had a history of dementia, obstructive and reflux uropathy, benign prostatic hypertrophy, other hydronephrosis, and stage four chronic kidney disease. The facility's failure to reassess the catheter status and update the care plan resulted in a discrepancy between the catheter size used and the physician's order. The resident was observed with a size 24 French catheter, while the physician's order indicated a size 16 French catheter. This discrepancy was not addressed, and no re-admission assessment or catheter assessment was completed. The clinical nurse specialist confirmed the lack of appropriate orders and assessments, highlighting the importance of ensuring the correct catheter size to prevent complications.
Staffing Deficiency on Elmwood Unit During Night Shift
Penalty
Summary
The facility failed to maintain sufficient nursing staff to provide care to residents on the Elmwood unit during the night shift from 11:00 P.M. to 7:00 A.M. This deficiency was identified through interviews and record reviews, revealing that the facility did not have staffing waivers in place and was unable to fill positions timely when staff called out. The facility assessment indicated a need for 3.58 hours of direct care per patient per day, but the actual staffing levels fell short of this requirement, particularly on the Elmwood unit, which houses residents with advanced cognitive loss and high care needs. Residents reported that during the night shift, they often did not receive assistance with basic needs such as changing and toileting until the end of the shift. The Resident Council minutes highlighted concerns about late medication administration and insufficient CNA staffing. Interviews with CNAs and nurses confirmed that staffing shortages were a recurring issue, with frequent no-call/no-shows and difficulties in finding replacement staff. This resulted in only one CNA being available on the Elmwood unit during certain shifts, which was insufficient to meet the needs of residents who required total care for activities of daily living. The facility's scheduler and clinical nurse specialist acknowledged the staffing issues, noting that the Elmwood unit required a higher level of care due to resident acuity. Despite attempts to adjust staffing models and cover shifts, the facility was unable to consistently maintain the required staffing levels. The administrator was unaware of the specific staffing shortages on the identified dates, and the facility did not provide evidence of meeting the required hours of direct care per patient per day during the survey period.
Failure to Ensure CNA Competency Evaluation
Penalty
Summary
The facility failed to ensure that a Certified Nurses Aide (CNA) demonstrated the necessary competencies to provide resident care, as required by regulations. Specifically, CNA #3 did not complete the annual competency evaluation for 2024, which is mandated to ensure continuing competence in skills and techniques necessary for resident care. The Facility Assessment Tool, dated July 2024, outlined the requirements for staff training and competencies, including a minimum of 12 hours of in-service training per year, dementia management training, and resident abuse prevention training. However, a review of CNA #3's employee record showed no evidence of a completed competency evaluation for the year. During an interview, the Administrator was unable to provide documentation of the completed evaluation or a facility policy regarding CNA competency evaluations.
Failure to Provide Follow-Up Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents, leading to deficiencies in their mental and psychosocial well-being. Resident #51, admitted with diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder, did not receive follow-up psychiatric services after an initial evaluation in March 2024. Despite recommendations for three-month follow-up visits, there was no evidence of further psychiatric consultations until January 2025, when the resident declined services. The social worker confirmed the lack of follow-up and acknowledged that the resident should have been offered additional psychiatric services before January 2025. Resident #23, admitted with Major Depressive Disorder and Congestive Heart Failure, also did not receive the recommended psychiatric follow-up. The resident's care plan included interventions for psychiatric consultation, and a physician's note in December 2024 recommended follow-up by the in-house psychiatric team. However, there was no documented evidence that the resident was seen by the psychiatric team following these recommendations. The social worker confirmed that the resident had not been referred for behavioral health follow-up despite the documented need. Both residents were cognitively intact and exhibited symptoms of depression and anxiety, with documented behavioral issues such as verbal outbursts and rejection of care. The facility's failure to ensure timely follow-up with psychiatric services, as recommended by healthcare providers, resulted in a deficiency in meeting the residents' behavioral health needs.
Improper Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that psychotropic medications administered were necessary for a resident, as evidenced by the lack of proper consent from the resident's Health Care Proxy (HCP). The resident, who was admitted with diagnoses including PTSD, cirrhosis, hallucinations, and altered mental status, was moderately cognitively impaired and had a diagnosis of delusional disorder and bipolar disorder. The resident's incapacity to make medication decisions was documented as indefinite due to progressive dementia. Despite this, the informed consent for the administration of Trazodone and Buspirone was signed by an individual other than the resident's HCP. The facility's policy on psychotropic medication management requires that each resident's drug regimen be free from unnecessary drugs and that consent for psychoactive medication be obtained from the resident or responsible party. However, the consent for the resident's psychotropic medications was signed by another resident's HCP, not the appropriate HCP. This oversight was confirmed during interviews with the Unit Manager and Clinical Nurse Specialist, who acknowledged that the consents should have been signed by the correct HCP but were not.
Incomplete Meal Intake Documentation for At-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as being at risk for weight loss. Specifically, the Certified Nurse Aides (CNAs) did not consistently document meal intake percentages for the resident, who was admitted with diagnoses including Alcohol Dependence, Traumatic Fracture, COPD, and Muscle Weakness. The resident experienced significant weight fluctuations, with a noted weight loss of 18.1 pounds from September to December 2024. Despite being identified as at risk for weight loss, the meal intake documentation was incomplete, with numerous instances of missing entries over several months. The facility's policy on nursing documentation requires nursing personnel to document information related to the resident's condition and care in the medical record. However, a review of the CNA flowsheets revealed that many opportunities for meal documentation were left blank, with 39 out of 90 in November, 35 out of 93 in December, and 25 out of 90 in January. Interviews with the Unit Manager and Dietician confirmed that CNAs are expected to document meal intakes after every meal, but this was not consistently done. The Dietician noted that he would not rely solely on the incomplete meal intake documentation for interventions, indicating a lack of accurate records to support resident care decisions.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to maintain proper infection control practices for three residents, leading to potential contamination and infection risks. For Resident #7, the staff did not appropriately manage the urinary drainage bags used for daytime and nighttime, which were observed hanging in the bathroom and making contact with the wall without being secured in a storage bag. The bags contained residual urine, and the staff did not follow a standard procedure for cleaning and storing these bags, as confirmed by interviews with the CNA, Nurse, and Infection Preventionist. Resident #47, who was severely cognitively impaired and dependent on staff for personal hygiene, was not assisted with hand hygiene before eating. The resident participated in a group activity with visibly soiled hands and was served a meal without handwashing, despite the presence of a dried brown substance on the hands. The Activity Aide admitted that hand hygiene was not performed before meals, which was against the expectations of the Director of Nursing, who emphasized the importance of hand hygiene in preventing infections. For Resident #11, the facility did not adhere to Enhanced Barrier Precautions (EBP) during a bolus feeding procedure. The nurse involved did not wear a gown or gloves as required by the EBP signage posted outside the resident's room. The Unit Manager confirmed that all staff should follow EBP protocols, including wearing appropriate personal protective equipment during high-contact care activities. The lack of compliance with EBP protocols placed the resident at risk for transmission of organisms.
Incomplete Daily Nursing Staff Data Posting
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting complete daily nursing staff data at the start of each shift. The posted information on the dry-erase board, accessible to residents and visitors, included only the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) scheduled for each shift. However, it did not include the total number and actual hours worked by these staff members, nor did it provide the facility's resident census. During interviews, the Receptionist and Scheduler confirmed that the staffing information was updated daily based on the schedule provided, but they were unaware of the requirement to include hours worked and resident census in the postings.
Delayed MDS Assessment for Hospice-Enrolled Resident
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Assessment in a timely manner for a resident who experienced a significant change in status. The resident, who was admitted to the facility with End Stage Renal Disease (ESRD) and Dementia, was enrolled in a hospice program, which required a Significant Change in Status Assessment (SCSA) to be performed. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, the SCSA should have been completed within 14 days of the determination of the significant change, which occurred when the resident was admitted to hospice. However, the SCSA for the resident was not completed until 20 days after the determination of the significant change in status. The Assessment Reference Date (ARD) was set for two days after the resident's enrollment in hospice, but the assessment itself was not finalized until much later, resulting in a delay. During an interview, the MDS Nurse acknowledged that the assessment was completed late and emphasized the importance of timely completion to ensure that the services provided met the resident's needs.
Involuntary Seclusion of Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from involuntary seclusion when a Certified Nurse Aide (CNA) tied a plastic bag from the door handle of their room to the hallway handrail. This action was taken to prevent one resident, who had a history of exit-seeking and wandering behaviors, from leaving the room while the CNA attended to another resident. The incident occurred during an evening shift when the unit was short-staffed, and the CNA was left alone to care for over 40 residents. The door remained tied shut for approximately two hours, confining both residents to their room against their will. Resident #1, who was severely cognitively impaired and had a history of wandering and exit-seeking behaviors, was found standing behind the door when it was eventually untied. Resident #4, who shared the room and was also severely cognitively impaired, was asleep during the incident. The facility's policy on abuse, neglect, and exploitation clearly defines involuntary seclusion as the separation of a resident from other residents or confinement to their room against their will. The CNA admitted to tying the door shut for safety reasons due to being overwhelmed by the staffing situation. The facility's investigation substantiated the allegation of involuntary seclusion based on staff statements and the CNA's admission. The Director of Nurses (DON) and other staff members confirmed the details of the incident, including the CNA's actions and the subsequent discovery of the tied door. The facility's policy was not followed, leading to the confinement of the residents and a failure to protect them from involuntary seclusion.
Failure to Report Involuntary Seclusion Incident
Penalty
Summary
The facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of an allegation of involuntary seclusion. On 01/13/24, Nurse #1 and Nurse #2 became aware that the door to a bedroom occupied by two ambulatory residents was tied shut with a plastic bag, preventing them from exiting the room at will. Despite being aware of the incident, both nurses did not report it to the Facility Administration until 01/15/24, when the Director of Nurses (DON) discovered a progress note about the incident. This delay in reporting violated the facility's policy, which requires immediate reporting of such allegations to the administrator or designee. The incident involved two residents, one of whom typically wandered the unit during the evening and overnight shifts, while the other usually stayed in bed during the night. The door was tied shut by a Certified Nurse Aide (CNA) who claimed it was done to keep one resident safe while attending to another. However, this action resulted in involuntary seclusion of both residents. The failure to report the incident immediately as required by the facility's policy placed other residents at risk for abuse. The deficiency was identified when the DON reviewed clinical notes and sought clarification from the involved nurses, who admitted to not reporting the incident to the administration as required.
Failure to Timely Report Allegation of Involuntary Seclusion
Penalty
Summary
The Facility failed to report an allegation of involuntary seclusion to the Department of Public Health (DPH) within the required two-hour timeframe. On 01/15/24 at approximately 7:30 A.M., the Director of Nurses (DON) #1 became aware of an incident that occurred on 01/12/24, where the door to the bedroom occupied by Resident #1 and Resident #4 was found to be tied shut. The incident was not reported to DPH until 6:07 P.M. on 01/15/24, more than ten hours after DON #1 learned of the incident. The Facility's policy mandates that any incident involving abuse must be reported to DPH within two hours. The incident was first noted in a Nurse Progress Note dated 01/13/24, which indicated that a plastic bag was found around the door of Resident #1's room at 11:30 P.M. on 01/12/24. Upon further investigation, it was revealed that CNA #1 had tied the door shut to keep Resident #1 safe while attending to another resident. Despite this, the incident was not reported immediately as required. The Administrator confirmed that the former DON was responsible for reporting the incident but failed to do so within the mandated timeframe.
Failure to Prevent Resident Elopement
Penalty
Summary
The Facility failed to ensure adequate supervision for Resident #2, who had dementia and was known to wander and exhibit exit-seeking behaviors. On 03/11/2024, Resident #2 exited the Facility without staff knowledge. The staff only became aware of the elopement after noticing that Resident #2's lunch tray was untouched and they could not locate him/her. Resident #2 was found later that day by the police, seated on the side of a road, four miles from the Facility, and was transported to the hospital for evaluation due to cold exposure but was stable and returned to the Facility. Resident #2 had been admitted to the secured unit of the Facility in December 2023, with diagnoses including dementia, anxiety disorder, and a history of traumatic brain injury. The Facility's policy on elopement indicated that residents at risk should be identified and preventative strategies implemented. Despite this, Resident #2's history of exit-seeking behavior was well-documented, with multiple instances of attempting to leave the unit and being redirected by staff. On the day of the incident, a Physical Therapy Assistant observed Resident #2 pushing the handle on an exit door but did not notify the nursing staff or redirect the resident. Interviews with staff revealed that Resident #2 was known to frequently attempt to exit the unit and that the exit doors did not shut quickly enough, allowing opportunities for elopement. The Facility's investigation suggested that Resident #2 might have exited through the main door, as visitors knew the code to enter and exit the unit. The Administrator confirmed that only staff members should have the code and that staff were expected to notify nursing staff if they observed a resident exit-seeking. The failure to provide adequate supervision and follow the Facility's elopement policy led to Resident #2's elopement and subsequent exposure to cold weather.
Insufficient Staffing Leads to Resident Safety Issues
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, leading to two significant incidents involving Resident #1 and Resident #2. On the evening shift of 01/12/24, Resident #2, who was moderately cognitively impaired and at risk for wandering, managed to leave the locked unit and was found on another unit. This occurred while the unit was understaffed, with only two CNAs and one nurse available to care for 40 residents. Additionally, CNA #1 admitted to securing Resident #1's door with a plastic bag to prevent him/her from wandering while she attended to another resident, as she was overwhelmed by the lack of staff support. Resident #1, who was severely cognitively impaired and had a history of wandering, was effectively placed in involuntary seclusion due to the staffing shortage. The facility's policy on abuse, neglect, and exploitation emphasizes the need for sufficient and qualified staff to meet residents' needs and prevent situations that could lead to abuse or neglect. However, the facility's staffing on 01/12/24 was significantly below the assessed need of 3.58 PPD for both nurses and CNAs, with actual staffing levels at 1.836 PPD. This shortfall directly contributed to the incidents involving Resident #1 and Resident #2. The facility's assessment indicated that the Elmwood unit housed residents with mid to late-stage dementia, requiring frequent staff interactions to maintain safety, which was not adequately provided on the night in question. Interviews with staff and the facility's investigation confirmed that the incidents were a result of insufficient staffing. CNA #1 reported feeling overwhelmed and unable to manage the residents' needs effectively, leading to the decision to secure Resident #1's door. The administrator acknowledged the staffing challenges and confirmed that the facility had not been able to meet its assessed staffing needs. The investigation substantiated the incident involving CNA #1 as involuntary seclusion and identified insufficient staffing as a contributing factor.
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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