Lee Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lee, Massachusetts.
- Location
- 620 Laurel Street, Lee, Massachusetts 01238
- CMS Provider Number
- 225749
- Inspections on file
- 21
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Lee Healthcare during CMS and state inspections, most recent first.
A resident with moderate vascular dementia, mood disturbance, and a history of agitation had a care plan calling for identification of triggers and use of de-escalation strategies. While the resident was seated at the nurses’ station, a CNA briefly touched the resident’s hat, and the resident immediately yelled and objected, causing that CNA to stop. Another CNA, despite witnessing this clear objection, then touched the hat, and after the resident loudly demanded that the CNA stop, touched it a second time. This taunting behavior provoked escalating agitation, with the resident becoming verbally abusive and physically destructive toward facility property, demonstrating a failure to treat the resident with dignity and to respect personal possessions.
The facility failed to maintain sanitary conditions in two unit kitchenettes, with crumb-laden toasters presenting a fire risk. Observations showed crumbs in toasters, and interviews revealed uncertainty about cleaning responsibilities. The Director of Housekeeping and Food Service Director were unsure who should clean the toasters, while the Regional Nurse suggested kitchen staff should maintain them.
A facility failed to maintain a clean environment in a resident's room, where surveyors observed brown, dried drip marks on the wall and windowsill over several days. Despite cleaning policies requiring regular cleaning, these marks remained visible to the resident, who was lying in bed facing the wall. The Director of Housekeeping acknowledged the oversight, noting that the room was scheduled for a deep clean and that such issues should have been addressed during routine cleaning.
A facility failed to complete a PASRR Level I Screening before admitting a resident with SMI, including PTSD and a later diagnosis of Borderline Personality Disorder. The Social Worker responsible was unavailable, and no other staff were trained to conduct the screening, leading to a delay in appropriate care evaluation.
A resident's wound dressing was not properly monitored or documented, as staff failed to obtain a physician's order and did not conduct ongoing assessments. The dressing, applied to the resident's elbow, was left unchanged for an extended period, leading to potential risks. The facility's protocol for weekly skin observations was not followed, resulting in the dressing being overlooked.
A resident with Parkinson's Disease and a femur fracture was discharged without a complete discharge summary or proper communication with follow-up care providers. The facility failed to ensure a comprehensive discharge plan, including necessary VNA services, leading to a delay in post-discharge care. Interviews revealed a lack of coordination among staff, with incomplete evaluations from Therapy and Social Work departments.
A facility failed to create a Trauma Informed Care Plan for a resident with PTSD, despite recommendations from a Social Services Evaluation. The resident's Comprehensive Care Plan lacked documentation of such a plan, and the Social Worker confirmed that it should have been developed but was not.
A facility failed to ensure complete CNA documentation for a resident with significant weight loss and nutritional risk. Despite a care plan requiring meal intake monitoring, records for June and July showed incomplete documentation. Interviews revealed that CNAs were expected to document each shift, but this was not consistently done, impacting the Dietician's ability to adjust dietary needs.
A facility failed to issue a Notice of Medicare Non-Coverage and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to a resident's guardian. The facility did not successfully contact the guardian or provide evidence of sending a certified letter, leaving the guardian uninformed about the end of Medicare Part A coverage and potential financial liabilities.
A facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative when the resident was transferred to the hospital. The resident's medical record lacked documentation of the notice, and interviews with staff revealed confusion about responsibility for issuing the notice. The Infection Preventionist confirmed that no education had been provided to nursing staff regarding this requirement.
Failure to Respect Resident’s Personal Possessions and Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions. The facility’s policy on Resident Rights and Responsibilities, revised January 2024, requires employees to treat all residents with kindness, respect, and dignity. Resident #1, admitted in August 2023, had diagnoses including moderate vascular dementia with mood disturbance and an anxiety disorder. A Quarterly MDS dated 09/30/25 documented moderate cognitive impairment with a BIMS score of 9/15. The resident’s Mood and Behavioral Care Plan, reviewed 12/03/25, noted vascular dementia with mood disturbance and agitation, with a history of hitting, kicking, grabbing, spitting, screaming, or threatening others, and identified interventions such as assessing triggers for aggression or agitation and providing de-escalation strategies including a quiet environment and reassurance. On 12/20/25, an altercation occurred between Certified Nurse Aide (CNA) #1 and Resident #1 at the nurses’ station. According to the facility’s investigation report and staff interviews, Nurse #1 was on the phone addressing a medical emergency while Resident #1 sat in a wheelchair at the nurses’ station, with CNA #1 and CNA #2 nearby. CNA #2 leaned forward to speak with the resident and briefly touched the top of the resident’s hat. Resident #1 immediately yelled and verbally objected, stating that the hat should not be touched, and CNA #2 stopped touching the hat after the objection. Despite having witnessed this objection, CNA #1 then approached and touched the resident’s hat. Nurse #1 and CNA #2 reported that Resident #1 loudly objected to CNA #1 touching the hat, demanded that CNA #1 stop, and that CNA #1 nevertheless touched the hat a second time. Nurse #1 stated that after the second touch, the resident’s agitation escalated, leading him to separate CNA #1 from the resident. When Nurse #1 returned to the nurses’ station area about 15 minutes later, Resident #1 remained very agitated, cursing and kicking a medication cart. CNA #1 acknowledged in a telephone interview that she touched the resident’s hat despite having seen the resident loudly object to CNA #2 doing so. The Director of Social Services later observed that the resident was “a bit revved up,” consistent with behavioral presentations that occurred at times for this resident, and the DON confirmed that CNA #1 had teased and provoked the resident by touching the hat despite the resident’s objections.
Sanitation and Safety Deficiency in Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary and safe conditions in two unit kitchenettes, specifically regarding the cleanliness of toasters. On July 24, 2024, observations revealed a crumb-laden toaster in Unit Two and crumbs lining the top and inside of the toaster slots in Unit One. These conditions presented a potential fire risk and were not in accordance with professional standards for food storage, preparation, distribution, and service. Interviews conducted on July 25, 2024, with the Director of Housekeeping and the Food Service Director revealed uncertainty about which department was responsible for cleaning the toasters. The Director of Housekeeping acknowledged the potential bacteria and fire risks associated with the crumb buildup. The Regional Nurse indicated that kitchenettes are cleaned twice monthly and as needed, suggesting that kitchen staff should maintain the toasters during restocking or fridge temperature checks. However, the lack of clarity in responsibility led to the observed deficiencies.
Failure to Maintain Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its units, specifically in a resident's room. Observations made by the surveyor on multiple occasions revealed multiple brown, dried drip marks on the wall and windowsill directly to the right of the resident's bed. These marks were visible to the resident, who was observed lying in bed facing the wall with the marks. The facility's cleaning policies, including the Complete Room Cleaning list and the Daily Patient Room Cleaning guidelines, require walls to be wiped as needed and vertical surfaces to be spot cleaned with a cloth and disinfectant. Despite these policies, the room in question was not adequately cleaned, as evidenced by the persistent presence of the drip marks over several days. The Director of Housekeeping confirmed that resident rooms are cleaned daily and deep cleaned monthly, and acknowledged that the room was scheduled for a deep clean prior to the surveyor's observations. The Director also stated that such drippings should have been addressed during both daily and deep cleaning routines, indicating a failure to adhere to the facility's cleaning protocols.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I Screening was completed prior to the admission of a resident diagnosed with serious mental illness (SMI). Specifically, the resident was admitted with diagnoses of Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder, and Anxiety Disorder, but the Level I Screening was conducted nine days after admission. Additionally, the screening did not include the resident's new diagnosis of Borderline Personality Disorder, which was identified after admission. The Social Worker responsible for completing the Preadmission Screenings was unavailable at the time of the resident's admission, and no other staff member was trained to perform this task. Consequently, the necessary screenings were not completed as required. The Social Worker was also unaware of the resident's PTSD diagnosis and the subsequent diagnosis of Borderline Personality Disorder, which would have necessitated a Post Admission Level I Screening and a Resident Review. This lack of awareness and communication among staff led to a delay in the evaluation and determination of appropriate care and services for the resident.
Failure to Monitor and Document Wound Dressing
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice concerning the application and monitoring of a wound dressing for a resident. The staff did not accurately assess the resident's skin, obtain a physician's order for a dressing applied to the resident's left elbow, or provide ongoing assessment of the area. This resulted in the dressing not being changed in a timely manner, putting the resident at risk for worsening wound status and infection. The resident was admitted with a diagnosis of a displaced intertrochanteric fracture of the right femur and had a care plan that included weekly skin condition checks and the application of barrier cream to certain areas. Observations revealed that a foam dressing applied to the resident's left elbow was not documented in the physician's orders or the treatment administration record. The dressing, dated ten days prior, was observed to be intact but later found to be lifted at the edges with dry tan drainage. Interviews with the nurse who applied the dressing and the infection preventionist/unit manager indicated a lack of awareness and documentation regarding the dressing. The facility's protocol for weekly full-body skin observations was not followed, as the dressing was not identified in the non-pressure ulcer evaluation.
Incomplete Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure a comprehensive discharge process for a resident, leading to a deficiency in the discharge summary and communication with follow-up care providers. The resident, who was moderately cognitively impaired and had been admitted with Parkinson's Disease and a femur fracture, expressed uncertainty about the discharge plan and desired a specific Visiting Nurse Agency (VNA) for post-discharge care. However, there was no documented discussion or arrangement for the resident's follow-up care, and the discharge summary was incomplete. The discharge planning process was inadequately executed, as evidenced by the lack of a completed discharge summary from the Therapy and Social Work departments. Although the nursing department completed their portion of the Discharge/Transfer Evaluation, the necessary information regarding ongoing community services, such as VNA services, was not included. The Social Worker and Director of Rehabilitation were unaware of who made the referral to the VNA, and the VNA contact confirmed that no referral had been made until after the resident's discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the discharge process. The Social Worker acknowledged that the Discharge/Transfer Evaluation should have been completed before the resident's discharge, and the Director of Rehabilitation admitted that the Therapy department failed to complete their portion of the evaluation. The Regional Nurse confirmed that the Social Work Department was responsible for making VNA referrals, which should have been done prior to discharge, but this was not completed, resulting in a delay in the resident receiving necessary post-discharge services.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident diagnosed with PTSD. The resident was admitted in May 2024, and the Social Services Evaluation conducted on 5/15/24 indicated that the resident had past experiences that were emotionally, spiritually, physically, or behaviorally upsetting. This evaluation recommended the creation of a Care Plan related to Trauma Informed Care. However, a review of the resident's Comprehensive Care Plan revealed no documentation of such a plan being developed. During an interview, the Social Worker acknowledged that a Trauma Informed Care Plan should have been created for the resident but was not.
Incomplete CNA Documentation for Meal Intake
Penalty
Summary
The facility failed to ensure complete and accurate documentation by a Certified Nurses Aide (CNA) for a resident with a history of significant weight loss and increased risk for nutritional decline. The resident, admitted in May 2022, had diagnoses of muscle wasting, atrophy, and chronic pain. A Dietician's Progress Note from June 2024 identified a significant weight loss of 7.8% over three months. The care plan, initiated in May 2022 and revised in May 2024, required monitoring and recording of meal intake every meal. However, the CNA documentation for June and July 2024 showed incomplete records, with only 58 of 90 meals in June and 36 of 73 meals in July having documented meal intake percentages. Interviews with facility staff revealed that meal intake documentation was expected to be recorded each shift. The Dietician noted that incomplete documentation hindered her ability to make necessary dietary adjustments, as she often had to seek additional information verbally from staff. The Regional Nurse confirmed that CNAs were not documenting meal intakes every shift as required, which was evident upon reviewing the resident's meal intake records for June and July 2024.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's guardian. This notice is crucial for informing the resident or their guardian about the end of Medicare Part A coverage and any potential financial liabilities for continued services. The deficiency involved a resident who was admitted in August 2023, and the facility did not successfully contact the guardian to inform them of the last covered day of Medicare Part A services, which was set for June 13, 2024. Attempts to contact the guardian on June 11, 2024, were unsuccessful, and the facility claimed to have sent a certified letter, but there was no evidence of this action. During an interview, the facility's administrator acknowledged the failure to provide the necessary documentation to the guardian. The administrator noted that the process should have included sending a certified letter and maintaining the return receipt for records, but no such receipt or evidence of mailing was found. This oversight left the resident's guardian uninformed about the termination of Medicare coverage and the potential financial responsibility for continued skilled services.
Failure to Provide Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative at the time of discharge. Specifically, the staff did not issue a Notice of Intent to Transfer and Discharge when the resident was transferred from the facility to the hospital. The resident was admitted to the facility in July 2023 and was transferred to the hospital on May 12, 2024. A review of the resident's medical record showed no documentation of the required notice being provided at the time of discharge or shortly thereafter. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of the notice. The Social Worker stated that she does not provide the notice when a resident is transferred to the hospital, indicating that it was the nursing staff's responsibility. The Infection Preventionist, who also served as the Unit Manager, confirmed that neither the resident nor their representative received the notice and acknowledged that no education had been provided to the nursing staff about this requirement.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
