Life Care Center Of Merrimack Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Billerica, Massachusetts.
- Location
- 80 Boston Road, Billerica, Massachusetts 01862
- CMS Provider Number
- 225546
- Inspections on file
- 20
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Life Care Center Of Merrimack Valley during CMS and state inspections, most recent first.
The facility failed to protect residents from neglect, resulting in severe pressure injuries and inadequate wound care. One resident's stage 4 pressure injury worsened due to incomplete skin checks and delayed antibiotic treatment, leading to hospitalization and death. Another resident developed a stage 4 pressure injury and osteomyelitis due to inadequate care. Additional residents experienced similar neglect, with the facility failing to implement necessary treatments and interventions. The wound care team, consisting of LPNs, lacked proper training, leading to inadequate wound management.
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. One resident developed a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. Another resident's pressure injury worsened without new interventions, and the facility did not arrange for a wound clinic follow-up. Additionally, the facility neglected to apply heel boots and ensure an air mattress was set correctly, contributing to the development and worsening of pressure injuries.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to worsening pressure injuries and infections in residents. The lack of documented competencies and oversight in the wound care program resulted in severe consequences, including hospitalization and death. Interviews revealed gaps in training practices and clinical oversight, contributing to inadequate resident care.
The facility failed to provide adequate training and oversight for wound care management, resulting in severe pressure injuries for three residents. The lack of a comprehensive QAPI plan and physician-supervised wound care program contributed to the worsening of these injuries, leading to hospitalizations and, in one case, death. The facility's administration did not address concerns raised by the Medical Director, and the nursing staff lacked the necessary competencies to manage the residents' conditions effectively.
The facility's governing body failed to ensure effective wound care management, resulting in three residents developing severe pressure injuries. The facility lacked consistent staff training and competency evaluations, and the wound care program was not properly supervised by a physician. The QAPI process did not address wound care issues, and transportation challenges further hindered residents' access to necessary care, leading to severe complications and one death.
The facility failed to ensure licensed nursing staff were competent in wound care, leading to severe outcomes for several residents. The Staff Development Coordinator admitted to only verbal competency reviews, lacking hands-on evaluations. As a result, residents suffered from worsening pressure ulcers and related complications, including hospitalization and death.
The facility failed to ensure the medical director implemented care policies and coordinated medical care, resulting in worsening pressure wounds for several residents. The QAPI plan did not address wound care, and the medical director was not actively involved in wound management. This led to severe infections, hospitalizations, and one resident's death. Staff interviews revealed a lack of communication and oversight in wound care practices.
The facility failed to maintain a comprehensive QAPI program addressing pressure ulcers, resulting in three residents developing worsening pressure injuries, infections, and hospitalizations, with one resident dying. The QAPI program lacked data-driven monitoring of wounds, and interviews revealed that wound care was not part of the QAPI focus, with no follow-up on identified concerns.
A resident admitted with complex medical conditions, including a surgical wound, did not receive a complete baseline care plan addressing wound management. The facility failed to implement necessary interventions, resulting in multiple pressure injuries. Staff interviews revealed that the resident would have benefited from an air mattress and updated care plan to reflect their high risk for skin breakdown.
The facility failed to schedule necessary specialist appointments for two residents with worsening wounds, despite recommendations from a Nurse Practitioner. Both residents experienced deteriorating conditions, leading to hospitalizations. Interviews revealed issues with arranging transportation for appointments and a reliance on external wound care expertise.
A dietary aide in an LTC facility failed to follow proper sanitation and food handling practices during breakfast service. The aide touched bread with bare hands and did not perform hand hygiene before donning new gloves, leading to contamination. The FSD confirmed that staff are expected to wash hands before tasks and not touch ready-to-eat food with bare hands.
The facility failed to effectively monitor and track infections, with the IP not documenting monthly line listings or tracking signs and symptoms daily. During a survey, three wound infections were found without active monitoring, and the IP was unaware of these cases. Additionally, a nurse did not follow Enhanced Barrier Precautions during wound care, failing to wear a gown as required.
The facility failed to implement person-centered care plans for two residents. One resident, with dementia and depression, required a mechanical lift with two staff for transfers, but was often transferred alone, contrary to the care plan. Another resident, with major depressive disorder and a history of alcohol use disorder, had an incomplete behavior care plan that did not address all behaviors. Staff interviews confirmed the care plans were not followed, risking resident safety.
A facility failed to change a resident's PICC line dressing weekly as ordered by the physician. Observations showed the dressing was not changed for over two weeks, despite the resident being on IV and antibiotic medications. The facility's policy required weekly dressing changes and measurements of the upper arm circumference and external catheter length, which were not documented until later. Interviews with staff confirmed the expectation of weekly dressing changes, but the progress notes did not reflect this practice.
A facility failed to follow dialysis care protocols by taking blood pressure readings on a resident's arm with a dialysis shunt, contrary to physician's orders. The resident's documentation incorrectly indicated the shunt's location, leading to repeated errors in care. Staff interviews confirmed awareness of the correct procedure, highlighting a discrepancy between knowledge and practice.
A resident was found with medication left unsupervised at their bedside, contrary to the facility's policy. The resident, who had intact cognition, was observed with an inhaler and pills within reach, despite not being authorized to self-administer these medications without staff supervision. The facility's policy required medications to be administered safely per physician's orders, which was not adhered to in this case.
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. One resident was documented as wearing heel boots when they were not, another had medication left unsupervised at their bedside despite records indicating it was administered, and a third had incorrect documentation regarding the location of a dialysis shunt, leading to improper blood pressure readings. Staff interviews confirmed these inaccuracies.
Neglect in Wound Care Leads to Severe Pressure Injuries
Penalty
Summary
The facility failed to protect four residents from neglect, resulting in severe pressure injuries and inadequate wound care. For one resident, the facility neglected to complete a full weekly skin check as ordered, failed to acknowledge and respond to initial wound cultures, and did not notify the medical doctor of the wound culture results. This led to a worsening stage 4 pressure injury to the coccyx, requiring antibiotics, surgical debridement, hospitalization, and ultimately resulted in the resident's death. The resident was admitted with diagnoses including Parkinson's disease and dementia, and was dependent on staff for all activities of daily living. Another resident developed a stage 4 pressure injury to the sacrum, resulting in osteomyelitis, due to the facility's failure to provide care and treatment to prevent the development of pressure ulcers. The facility also failed to respond to and implement interventions when the resident developed a deep tissue pressure injury to the left heel. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Additional residents experienced similar neglect, with one developing a stage 3 pressure injury to the lower back and another experiencing a worsening sacral wound with signs of infection. The facility failed to implement treatments, physician orders, and care plan interventions, resulting in hospitalization and the need for extensive medical treatment. The facility's wound care team, consisting of LPNs, lacked proper training and competencies, leading to inadequate wound management and failure to refer residents to a wound clinic for specialized care.
Inadequate Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. For one resident, the facility did not perform a full skin assessment as ordered, leading to the development of a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. The resident's condition deteriorated, and the wound continued to worsen despite multiple antibiotic treatments. The facility also failed to notify the physician of the wound culture results in a timely manner, resulting in delayed treatment. Another resident experienced a worsening of their pressure injury, with signs of infection that were not addressed with new interventions. The facility did not arrange for a follow-up at a wound clinic as recommended by the nurse practitioner. Additionally, the facility failed to implement physician orders and care plan interventions for another resident, leading to the development of multiple pressure injuries, including a stage 3 pressure injury that required hospitalization. The facility also neglected to apply heel boots as ordered for one resident and failed to ensure an air mattress was set to the correct setting for another resident. These oversights contributed to the development and worsening of pressure injuries, highlighting a pattern of inadequate wound care and failure to follow established protocols and physician orders.
Inadequate Training and Competency in Wound Care
Penalty
Summary
The facility failed to ensure that the nursing staff were adequately trained and demonstrated the necessary competencies to provide the required level of care for residents, as outlined in the Facility Assessment. Specifically, the licensed nursing staff lacked training and competency in identifying, assessing, evaluating, intervening, and responding to significant changes in wound conditions. This deficiency affected four residents, leading to the worsening of pressure injuries, infections, and in one case, death. The facility's failure to provide adequate training and competency assessments resulted in severe consequences for the residents involved. The report highlights that the facility did not conduct the necessary training and competency evaluations for 31 out of 36 staff members, as required by the Facility Assessment. The lack of documented evidence of completed competencies in skin and wound care was evident in the educational records of the licensed nurses. The facility's Wound Care Manual and the Life Care Center Wound Tool Box were not effectively utilized to ensure clinical competency, as indicated by the absence of documented competencies for the designated wound nurses. Interviews with staff and management revealed that the facility's wound care program was inadequately managed. The Director of Nurses acknowledged the lack of clinical oversight and the absence of a Registered Nurse to interpret wound data. The Staff Development Coordinator admitted to not conducting hands-on competency assessments, relying instead on verbal instructions. The Regional Director of Clinical Services and the Nursing Home Administrator expressed expectations for staff training and competencies, but the facility's practices did not align with these expectations. The deficiency in training and competency assessments contributed to the inadequate care provided to residents with pressure injuries.
Inadequate Wound Care Management Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure competent clinical care and oversight for the prevention and treatment of pressure injuries, leading to severe consequences for three residents. The administration did not provide adequate education, training, and competency evaluations for nursing staff responsible for wound care management. This lack of training resulted in the failure to perform necessary skin checks, wound evaluations, and updates to the physician and care plans when significant changes occurred. Consequently, one resident developed a stage 4 pressure ulcer with purulent drainage and odor, which worsened due to inadequate care. The facility's Quality Assurance and Performance Improvement (QAPI) program did not address concerns raised by the Medical Director regarding documentation, wound dressings, lab services, and wound staging. Despite the Medical Director's identification of these issues, the facility did not implement a comprehensive QAPI plan to address them. The Nursing Home Administrator acknowledged noticing trends with wounds but failed to incorporate wound care into the QAPI program, resulting in a lack of follow-up on identified concerns. The absence of a physician-supervised wound care program contributed to the worsening of pressure injuries for the residents. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and led to hospitalization and death. Another resident's stage 4 pressure injury required surgical intervention and multiple hospitalizations, while a third resident's worsening wound necessitated hospitalization and intravenous antibiotics. The facility did not have a wound physician on-site, and the attending physician relied on the wound care team, which lacked the necessary expertise and oversight to manage the residents' conditions effectively.
Inadequate Wound Care Management and Oversight
Penalty
Summary
The facility's governing body failed to provide adequate oversight and accountability for quality of care, specifically in the area of comprehensive wound care management. The governing body did not ensure consistent and effective nursing staff education and training, as outlined in the Facility Assessment, which resulted in a lack of competent quality of care and effective wound care management. This deficiency led to three residents developing pressure injuries that worsened, became infected, required hospitalization, and in one case, resulted in death. The facility's wound care program was not effectively implemented or supervised by a physician, as required for pressure ulcer prevention and care. The Facility Assessment Tool indicated that the facility employed a Wound Care Nurse for each resident unit, but staffing data for these positions was incomplete. Additionally, the facility failed to conduct necessary training and competency evaluations for clinical nursing staff, as evidenced by the review of personnel files and educational records. This lack of training and competency evaluation contributed to the worsening of residents' pressure injuries. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, revealed that the facility's QAPI process did not adequately address wound care issues. The wound care nurses were not involved in the QAPI meetings, and there was no documentation of wound care concerns or improvement activities in the QAPI plan. The facility also faced challenges with transportation for residents needing external wound care, and there was no wound physician rounding in the facility. These systemic issues contributed to the inadequate management of residents' pressure injuries, leading to severe complications and, in one case, death.
Inadequate Wound Care Competency Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the resources necessary to care for its residents, particularly in the area of wound care. The assessment did not ensure that licensed nursing staff were competent in wound care, which is critical given the range of medical conditions treated at the facility, including various types of wounds. The facility's training and competency evaluations were inadequate, as evidenced by the lack of documented competencies in skin and wound care for the majority of the licensed nursing staff. The Staff Development Coordinator (SDC) admitted that the orientation process involved only verbal reviews of nursing competencies, without hands-on evaluations. This approach was insufficient to ensure that staff were competent in providing the necessary care for residents, particularly in wound management. The SDC acknowledged that many competencies had not been completed for clinical staff, and she was attempting to catch up on these requirements. Interviews with the Nursing Home Administrator (NHA), Director of Nurses (DON), and Regional Director of Clinical Services confirmed that staff competencies were expected to be completed upon hire and annually, but this was not being effectively implemented. As a result of these deficiencies, several residents suffered from worsening pressure ulcers and related complications. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened to the point of gangrene and necrosis, ultimately leading to hospitalization and death. Another resident developed a Stage 4 pressure injury and additional complications, while a third resident's sacral pressure ulcer worsened despite documentation of infection, leading to hospitalization and surgical interventions. These incidents highlight the facility's failure to provide adequate training and competency evaluations for wound care, resulting in severe consequences for the residents involved.
Failure in Medical Oversight Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure that the medical director was responsible for implementing resident care policies and coordinating medical care, leading to severe consequences for several residents. The medical director did not adequately participate in the Quality Assessment and Assurance (QAA) committee activities related to wound care, and there was a lack of follow-up on identified concerns. The facility's QAPI plan did not include wound care as a focus area, and the wound nurses were not involved in the QAPI process. This lack of coordination and oversight resulted in worsening pressure wounds for multiple residents, leading to severe infections, hospitalizations, and in one case, death. Several residents suffered from deteriorating pressure ulcers due to inadequate wound management. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and became infected, leading to gangrene, necrosis, and ultimately death after hospitalization and surgical intervention. Another resident developed a Stage 4 pressure injury with osteomyelitis, requiring multiple hospitalizations and surgical debridement. A third resident developed a Stage 3 pressure injury and multiple other pressure injuries, with a failure to arrange necessary wound clinic follow-ups. Interviews with facility staff revealed a lack of involvement from the medical director and other medical professionals in wound care management. The unit managers and the director of nursing were not actively participating in wound rounds, and the medical director admitted to relying on the wound care team for assessments and treatment recommendations. The medical director was not a wound care expert and was not always informed of changes in treatment orders, indicating a significant gap in communication and oversight of wound care practices within the facility.
Deficiency in QAPI Program Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, particularly concerning pressure ulcers and wounds. This deficiency resulted in three residents developing pressure injuries that worsened, became infected, and required hospitalization, with one resident ultimately dying due to neglect. The facility's QAPI program did not include data-driven information or monitoring of pressure ulcer wounds, and there was no documentation of a QAPI plan relating to the care and services of pressure wounds or skin injuries. Resident #264 developed multiple pressure ulcers, including a sacral pressure ulcer that worsened and showed symptoms of infection, such as gangrene and necrosis. Despite being treated with antibiotics, the wound worsened, leading to hospitalization and surgical debridement due to osteomyelitis, ultimately resulting in the resident's death. Resident #97 developed a Stage 4 pressure injury to the sacrum, which required antibiotics, surgical debridement, and multiple hospitalizations. The resident also developed additional pressure injuries and failed to receive a wound clinic follow-up. Resident #103's sacral pressure ulcer worsened in the facility, and despite documentation of infection, the treatment remained unchanged, leading to hospitalization and multiple surgical interventions. Interviews with facility staff revealed that the QAPI process for wounds was not effectively implemented. The Regional Director of Clinical Services and the Director of Nursing acknowledged the existence of a QAPI process for wounds, but the Nursing Home Administrator (NHA) admitted that wound care had not been a part of the QAPI program for the year. The NHA also confirmed that the facility's wound nurses were not involved in QAPI meetings, and there was no follow-up on the Medical Director's identified concerns related to wounds. The lack of a comprehensive QAPI plan and failure to address wound care issues contributed to the worsening conditions of the residents.
Failure to Implement Baseline Care Plan Leads to Pressure Injuries
Penalty
Summary
The facility failed to complete a baseline care plan for a resident who was admitted with multiple complex medical conditions, including a surgical wound on the lower leg. The resident was at risk for developing pressure injuries, as indicated by their Minimum Data Set (MDS) assessment and Braden Scale score. Despite these risks, the baseline care plan did not include specific goals or nursing interventions for wound management, and the facility did not implement necessary interventions to prevent the development of pressure injuries. As a result of these omissions, the resident developed multiple pressure injuries, including a Stage 3 pressure injury on the lower back, a Stage 2 injury on the right buttock, a Stage 1 injury on the right lateral foot, and deep tissue injuries on the right outer calf and right heel. The facility's failure to update the care plan and implement recommended interventions, such as the use of an air mattress and proper offloading techniques, contributed to the worsening of the resident's condition. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the resident would have benefited from an air mattress upon admission and that the care plan should have been updated to reflect the resident's high risk for skin breakdown. The DON acknowledged that wound treatment orders and recommendations should have been followed, and the necessary interventions should have been documented and assessed from the time of admission.
Failure to Schedule Specialist Appointments for Wound Care
Penalty
Summary
The facility failed to ensure that recommended specialist appointments were scheduled for two residents, leading to deficiencies in their care. Resident #60, who was admitted with multiple complex diagnoses including multiple sclerosis, cellulitis, and diabetes with a foot ulcer, was not scheduled for a necessary outpatient appointment at the wound clinic despite recommendations from a Nurse Practitioner. The resident's condition worsened, resulting in hospitalization for an infected pressure wound. The medical records did not indicate that the resident was seen by the wound clinic as recommended, and interviews with staff revealed issues with arranging transportation for appointments. Similarly, Resident #103, who was admitted with depression, diabetes, and a pressure ulcer, was not scheduled for a wound clinic appointment despite a Nurse Practitioner's recommendation. The resident's condition deteriorated, leading to hospitalization for a worsening sacral wound that resulted in osteomyelitis and the need for surgical intervention. The facility's failure to schedule the necessary appointment was compounded by transportation issues, as noted by the Director of Nurses during interviews. Interviews with facility staff, including the Director of Nurses and a Physician, highlighted a reliance on external wound care expertise and the challenges faced in securing transportation for residents to attend specialist appointments. The lack of in-house wound care expertise and the failure to implement recommended specialist consultations contributed to the deficiencies observed in the care of both residents.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a breakfast tray line service. A dietary aide was seen touching bread with bare hands without wearing disposable gloves, which is against the facility's policy for safe food handling. The aide was also observed removing gloves, leaving her station, and entering the dry storage room to obtain new loaves of bread without washing her hands or performing hand hygiene. She then put on a new set of gloves, which were contaminated due to the lack of hand hygiene, and proceeded to handle the bread with these contaminated gloves. During an interview, the Foodservice Director (FSD) stated that dietary staff are expected to wash their hands before performing any task in the kitchen, before putting on new gloves, and when changing tasks. The FSD also mentioned that staff should not touch ready-to-eat food with bare hands. These observations and statements indicate a failure to follow the facility's policy on safe food handling, which is designed to prevent the risk of foodborne illness.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of monitoring, tracking, and analyzing of infections. The Infection Preventionist (IP) did not document monthly line listings for tracking antibiotics or provide documentation of signs and symptoms of infections related to antibiotic selection and continuations. The IP admitted to not tracking signs and symptoms of infections daily and only reviewing antibiotic use at the end of each month. During the survey, it was found that there were three wound infections in the facility with no active infection control monitoring or documentation, and the IP was unaware of these infections requiring antibiotic therapy. Additionally, the facility did not adhere to its policy on Enhanced Barrier Precautions (EBP) during wound care. A nurse was observed performing wound care without wearing a gown, despite a sign indicating the need for EBP, which includes gown and glove use for residents with wounds. The nurse acknowledged forgetting to wear a gown, and the Director of Nurses confirmed the expectation for staff to wear a gown during dressing changes.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the facility did not properly implement an Activities of Daily Living (ADL) care plan. This resident, who was admitted with diagnoses including dementia and depression, required a mechanical lift with two staff for transfers. However, records indicated that staff frequently transferred the resident alone, contrary to the care plan. Interviews with multiple CNAs and the Unit Manager confirmed that the care plan was not followed, which could potentially lead to injuries during transfers. For another resident, the facility failed to develop a person-centered behavior and history of substance abuse care plan. This resident, admitted with major depressive disorder, hallucinations, and psychotic disorder, had a history of alcohol use disorder. The behavior care plan did not include all of the resident's behaviors, such as hallucinations and a history of alcohol abuse. The Social Worker acknowledged that the care plan was not comprehensive and did not personalize the resident's paranoid delusions. The facility's policies require comprehensive, person-centered care plans that include measurable objectives and time frames to meet each resident's needs. However, the facility did not adhere to these policies, resulting in incomplete and improperly implemented care plans for the two residents. This lack of adherence to care plans was confirmed through interviews with staff, including CNAs, the Unit Manager, and the Director of Nursing, who all emphasized the importance of following care plans to ensure resident safety and well-being.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that the PICC line dressing for a resident was changed as ordered by the physician. The facility's policy required sterile dressing changes at least weekly, but observations revealed that the dressing on the resident's PICC line was dated 11/4/24, and had not been changed by 11/19/24. The resident, who was cognitively intact, confirmed that while nurses looked at the dressing, they did not recall anyone removing it entirely. The physician's orders specified that the PICC line dressing should be changed weekly, with measurements of the upper arm circumference and external catheter length. However, the medical record indicated that these measurements were not documented until 11/20/24. Interviews with nursing staff confirmed that PICC line dressings should be changed every seven days, and the Director of Nurses expected that the line and insertion site would be assessed with each use. Despite this, the progress notes failed to indicate that the dressing was changed on the specified date, highlighting a lapse in adherence to the facility's policy and physician's orders.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. Specifically, the facility did not adhere to the physician's orders regarding the correct arm for blood pressure readings. The resident, who has a dialysis shunt on the right arm, had blood pressure readings taken on this arm 22 times since March 2024, despite the physician's order incorrectly indicating the left arm as the location of the shunt. This discrepancy was noted in the resident's physician's orders, Kardex, and care plans, all of which incorrectly documented the shunt's location. Interviews with the Unit Manager and the Director of Nursing confirmed that the resident's dialysis shunt has always been on the right arm since the Unit Manager began working at the facility. Both staff members acknowledged that blood pressure readings should not be taken on the arm with the dialysis shunt due to potential negative implications, such as clotting around the dialysis port. Despite this knowledge, the facility's documentation and practice did not reflect the correct arm for blood pressure readings, leading to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored as required for a resident, leading to a deficiency. Specifically, medication was left at the bedside of a resident who was unsupervised by staff. The resident, who had intact cognition, was observed with an inhaler and later with a medicine cup containing pills on the bedside table within reach. The resident shared the room with a roommate, and there were no staff present during these observations. The facility's policy on medication administration indicated that medications should be administered safely and appropriately per physician's orders. However, the resident's physician's orders did not include self-administration of levothyroxine or omeprazole, and the resident was only permitted to self-administer an inhaler with staff present. Interviews with the nurse and the Infection Preventionist confirmed that the medications should not have been left at the bedside unsupervised, and the Director of Nursing acknowledged that this was not in accordance with the facility's policy.
Inaccurate Medical Documentation for Residents
Penalty
Summary
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. For one resident, the facility's records inaccurately indicated that the resident was wearing heel boots as ordered to prevent pressure ulcers, when in fact, the resident was observed without them on multiple occasions. The heel boots were not found in the resident's room, and staff interviews confirmed that the boots were in the laundry room, yet documentation falsely stated they were in use. Another resident's records inaccurately documented the administration of medication. The resident was observed with medication at their bedside, unsupervised, which had not been administered as per the physician's orders. The overnight nurse had documented that the medication was given, despite it being left at the bedside. Interviews with staff confirmed that the medication should not have been left unsupervised and that the documentation was incorrect. For a third resident, the facility's records inaccurately documented the location of a dialysis shunt. The resident's medical records, including physician's orders and care plans, incorrectly stated the shunt was on the left arm, while observations and interviews confirmed it was on the right arm. This discrepancy led to incorrect blood pressure readings being taken on the arm with the shunt, contrary to medical guidelines. Staff interviews acknowledged the error in documentation and the potential risk it posed.
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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