Life Care Center Of Stoneham
Inspection history, citations, penalties and survey trends for this long-term care facility in Stoneham, Massachusetts.
- Location
- 25 Woodland Road, Stoneham, Massachusetts 02180
- CMS Provider Number
- 225732
- Inspections on file
- 19
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Life Care Center Of Stoneham during CMS and state inspections, most recent first.
A resident experienced an unwitnessed fall and was found on the floor by staff. Despite the resident's complaints of pain, Nurse #1 did not assess for injuries and instead moved the resident without calling for emergency assistance. The incident was not documented or reported to the oncoming staff, leading to a delay in care. The resident was later diagnosed with a hip fracture at the hospital.
A resident experienced an unwitnessed fall and was found in pain, but the nurse failed to assess, document, or report the incident. The resident was later diagnosed with a hip fracture at the hospital. The facility's policy for fall management was not followed, leading to a delay in medical intervention.
A resident experienced an unwitnessed fall and was found in pain by a CNA, who repeatedly requested a nurse's assessment. The nurse failed to perform a pain assessment, administer medication, or notify a physician, despite the resident's clear expressions of pain. The resident was later diagnosed with a hip fracture at the hospital. The facility did not adhere to its pain management policies, leading to a delay in appropriate medical intervention.
The facility employed a nurse under a state waiver without verifying her graduation from a board-approved nursing program, as required by state law. The nurse, who graduated from a Florida university, lacked an active Massachusetts nursing license, and the facility did not obtain independent verification of her educational credentials. The DON and Corporate Recruiter acknowledged the oversight, and the nurse had worked over 670 hours without proper verification.
The facility failed to maintain a dignified existence for residents needing meal assistance. A staff member was overheard referring to residents as 'feeders' while assisting a resident with their meal. The facility's policy emphasizes treating residents with dignity, including avoiding such labels. The DON confirmed that using the term 'feeders' is not dignified.
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies. A resident with severe cognitive impairment did not have a care plan for a new skin tear, while another lacked a plan for ADL needs. Additionally, a cognitively intact resident at risk for pressure ulcers did not receive weekly skin checks as required.
A resident with a fracture and muscle weakness was observed with dirty fingernails over several days, despite requiring extensive assistance with ADLs. The resident, who was cognitively intact and did not refuse care, reported not receiving help with nail cleaning. Staff interviews confirmed that nail care should be part of daily ADL care, yet it was not provided, resulting in a deficiency.
A resident with severe cognitive impairment was found with an unlabeled bandage covering a skin tear on their hand. The facility failed to notify the physician or responsible party, obtain a treatment order, or document an assessment of the skin tear, contrary to their policy. The resident's care plan and medical records lacked documentation of the skin tear or treatment.
A resident with an unstageable pressure ulcer on the right heel did not receive the necessary treatment as ordered by the physician. Despite orders to wear Prevalon boots while in bed, the resident was observed multiple times without them. Interviews with staff confirmed the boots were not applied, and the Director of Nursing expected staff to follow orders and document any refusals, which was not done.
The facility failed to ensure proper hand hygiene in its food service operations. A diet aide was observed not washing hands after removing gloves and contaminating clean hands by turning off the water with them. This improper practice was repeated multiple times, despite the Food Service Director's confirmation that staff should follow proper hand washing techniques.
The facility failed to maintain accurate medical records for two residents. One resident, with severe cognitive impairment and a pressure ulcer, was documented as wearing Prevalon boots, but observations showed otherwise. Another resident, also with severe cognitive impairment, had a skin tear that was not documented in the skin assessment, despite being observed with a bandage. The DON confirmed the inaccuracies in documentation.
A resident with advanced Alzheimer's and chronic constipation did not have a comprehensive care plan addressing their medical needs, despite receiving multiple bowel medications and interventions. The facility's policies required a person-centered care plan, but the resident's plan lacked goals, outcomes, and interventions for constipation and abdominal pain. Interviews with staff confirmed the resident's ongoing issues and the use of interventions like a Foley catheter for gas relief, yet these were not documented in the care plan.
A resident with a history of constipation and abdominal distention received inadequate care due to the nursing staff's lack of competency in rectal tube procedures. The facility did not stock rectal tubes, leading to the use of a Foley Catheter instead. Nursing staff were unfamiliar with the procedure and did not document it properly, despite having a policy in place. The facility also failed to provide necessary training, contributing to the deficiency.
Neglect in Resident Fall Incident
Penalty
Summary
The facility failed to protect a resident from neglect during an incident that occurred overnight. A resident experienced an unwitnessed fall and was found on the floor by staff. Despite the resident's complaints of pain and visible distress, Nurse #1 did not assess the resident for injuries. Instead, Nurse #1 picked the resident up from the floor, placed them in a wheelchair, and then transferred them back to bed without conducting any assessment or calling for emergency medical assistance. Certified Nurse Aide (CNA) #1 reported the resident's pain to Nurse #1, who dismissed the concerns and did not take any further action. Nurse #1 completed his shift without documenting the incident or notifying the oncoming staff about the fall. As a result, the day shift staff were unaware of the fall and unable to provide appropriate care when the resident continued to express severe pain. The resident was later transferred to the hospital, where they were diagnosed with a left hip fracture. The facility's policies on abuse and neglect, as well as resident rights, were not followed. The Director of Nurses (DON) confirmed that there was no documentation of the fall, no nursing assessment, and no notification to the physician or facility management. The lack of immediate action and proper reporting by Nurse #1 led to a delay in the resident receiving necessary medical care.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to provide care and services that met professional standards of nursing practice for a resident who experienced an unwitnessed fall during the overnight shift. Despite the resident crying out in pain, Nurse #1 did not perform any assessment before moving the resident from the floor to a wheelchair and then to the bed. Nurse #1 also failed to document the fall, complete an incident report, or inform the oncoming nursing staff about the incident and the resident's complaints of pain. The resident, who had a history of falls and other medical conditions such as rhabdomyolysis, hypertension, and orthostatic hypotension, was later found by the day shift staff to be in severe pain. The resident was subsequently transferred to the hospital, where a left hip fracture was diagnosed. The facility's policy required a thorough assessment before moving a resident after a fall, documentation of the incident, and notification of the physician and family, none of which were followed by Nurse #1. Interviews with staff revealed that Nurse #1 was unresponsive to the resident's pain and did not follow the facility's procedures for fall management. The CNA who found the resident on the floor reported that Nurse #1 dismissed her concerns and did not perform any assessments. The Unit Manager and Director of Nursing confirmed that there was no documentation or assessment completed by Nurse #1, and the incident was not communicated to the oncoming staff, leading to a delay in appropriate medical intervention for the resident.
Failure in Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who experienced an unwitnessed fall during the overnight shift. The resident was found on the floor by a CNA, crying out in pain, and the CNA immediately called for assistance from a nurse. Despite the resident's clear expressions of pain and the CNA's repeated requests for the nurse to assess the resident, the nurse did not perform a pain assessment, administer any pain medication, or notify the physician about the resident's condition. As a result, the resident continued to experience severe pain and was later diagnosed with a left hip fracture after being transferred to the hospital. The resident had a history of medical conditions including rhabdomyolysis, hypertension, orthostatic hypotension, bradycardia, and a history of falls. The resident's care plan included interventions for pain management, such as anticipating the need for pain relief and responding immediately to complaints of pain. However, on the night of the incident, the nurse did not adhere to these interventions, and there was no documentation of any actions taken to address the resident's pain. The resident's medication administration record indicated that the resident had only requested pain medication once prior to the incident, and no new orders were obtained to manage the acute pain following the fall. The incident report and subsequent interviews revealed that the nurse dismissed the CNA's concerns and failed to follow the facility's policies for assessing and managing changes in a resident's condition. The nurse did not document the fall, notify the physician, or complete a pain assessment, which led to a delay in appropriate medical intervention. The resident was eventually transferred to the hospital, where a displaced proximal left femoral subtrochanteric fracture was diagnosed, requiring surgical intervention.
Failure to Verify Nursing Credentials
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable state laws. Specifically, the facility employed a nurse under a state waiver without verifying that the nurse had graduated from a board-approved nursing program. The Department of Public Health Circular Letter outlines that individuals practicing under a waiver must have graduated from a board-approved nursing program, and the facility must independently verify this information. However, the facility did not obtain independent verification or official documentation from the nursing education program to confirm the nurse's completion of a board-approved program. During the survey, it was revealed that the nurse in question, who had graduated from Nova Southwestern University in Florida, did not have an active nursing license in Massachusetts. The Director of Nurses (DON) and the Corporate Recruiter acknowledged the lack of verification and documentation in the nurse's personnel file. The DON admitted that the nurse should not have been working at the facility without proper verification of her educational credentials. The nurse had worked over 670 hours at the facility without the necessary confirmation of her qualifications.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain a dignified existence for residents requiring assistance with meals. During an observation, a staff member was overheard yelling into the hallway to another staff member to assist with breakfast, referring to residents as 'feeders.' This occurred while the staff member was assisting a resident with their meal in the resident's room. The facility's policy on dignity, reviewed on 9/25/23, emphasizes treating residents with dignity and respect, including addressing them by their chosen name or pronoun and avoiding labels such as 'feeders.' During an interview, the Director of Nurses confirmed that referring to residents as 'feeders' is not dignified.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. For one resident with severe cognitive impairment, the facility did not create a care plan for a new skin tear on the left hand, despite the presence of an unlabeled and undated bandage observed over several days. The Director of Nursing acknowledged that a care plan should have been developed for the skin tear and its treatment. Another resident, also with severe cognitive impairment, did not have a care plan addressing their specific Activities of Daily Living (ADL) needs, such as assistance with lower body care. The Director of Nursing confirmed that a care plan should have been developed for the resident's ADL needs. Additionally, a third resident, who is cognitively intact and at risk for pressure ulcers, did not receive the weekly skin checks as outlined in their care plan. The facility's policy required weekly skin assessments, but records showed only one skin check was completed, with no documentation of refusal by the resident.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary nail care for a resident who was unable to perform activities of daily living independently. The resident, admitted with a fracture of the right femur and muscle weakness, was observed multiple times with a dark black substance under the fingernails of the left hand. Despite being cognitively intact and not exhibiting any refusal of care behaviors, the resident reported not receiving assistance with cleaning their nails, which was confirmed by observations over several days. Interviews with facility staff, including a CNA and a nurse, revealed that nail care should be part of the daily ADL process, and there was no documentation of the resident refusing care. The resident's care plan indicated a need for extensive assistance with personal hygiene, yet the necessary nail care was not provided, leading to the deficiency noted by the surveyors.
Failure to Document and Treat Resident's Skin Tear
Penalty
Summary
The facility failed to implement standards of quality care for a resident with severe cognitive impairment, who was dependent on staff for activities of daily living. The resident was observed with an unlabeled and undated bandage on their left hand, which covered a skin tear. The facility did not notify the physician or responsible party about the new skin tear, did not obtain a treatment order, and failed to document an assessment of the skin tear. The facility's policy required a head-to-toe inspection upon admission and weekly thereafter, with documentation of any new skin alterations, obtaining treatment orders, and notifying the physician and responsible party. The resident's medical record did not indicate any physician's order for the treatment applied to the skin tear, nor was there any documentation of the skin tear in the most recent skin integrity update assessment or the physician's visit note. The care plan for the resident also lacked any mention of the skin tear or treatment. The Director of Nursing confirmed that the necessary steps, such as creating a risk report, notifying the physician, obtaining treatment orders, notifying the responsible party, and documenting these actions, were not taken.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers from developing. The resident, who was admitted in July 2024, had an unstageable pressure ulcer on the right heel and was diagnosed with Type II Diabetes. The physician had ordered the resident to wear Prevalon boots while in bed or not walking, starting from mid-July 2024. However, observations on multiple occasions in September 2024 revealed that the resident was in bed without the Prevalon boots, and none were found in the room. The resident's care plans included interventions for the pressure ulcer, such as treatment as ordered and the use of Prevalon boots. Despite these interventions, the resident was repeatedly observed without the boots. Interviews with the CNA and the nurse responsible for the resident's care confirmed that the boots were not applied as required. The Director of Nursing stated that staff should follow medical orders and document any refusal by the resident to wear the boots, but there was no documentation of such refusals.
Improper Hand Hygiene in Food Service
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety by not ensuring proper hand hygiene among its staff. During an observation of the breakfast tray line, a diet aide was seen rolling flatware into napkins while wearing gloves. After removing the gloves, the aide did not wash his hands before touching various surfaces, including a food truck and a door handle, and then left the kitchen. Upon returning, the aide washed his hands but contaminated them by using his clean hands to turn off the water, before putting on new gloves and resuming his task. This improper hand hygiene practice was repeated multiple times, as the diet aide left the kitchen with the food truck on two more occasions, each time failing to perform hand hygiene after glove removal. The aide continued to wash his hands improperly by turning off the water with clean hands, leading to contamination. The Food Service Director confirmed that staff are expected to wash their hands after removing gloves and to use proper hand washing techniques, including using a paper towel to turn off the water.
Inaccurate Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in documentation. For one resident, who was admitted with an unstageable pressure ulcer and severe cognitive impairment, nurses documented in the Treatment Administration Record (TAR) that the resident wore Prevalon boots while in bed. However, multiple observations over several days showed the resident in bed without the boots, and they were not found in the room. The nurse responsible for the resident acknowledged the discrepancy, noting that the boots should have been on as per the night nurse's documentation. For another resident with severe cognitive impairment and a history of falls, a skin assessment inaccurately documented the absence of a skin tear, despite the presence of a bandage on the resident's left hand. Observations revealed a skin tear under the bandage, which was not recorded in the assessment. The Director of Nursing confirmed that the skin assessment should have accurately noted the skin tear, highlighting a failure in maintaining accurate medical records.
Failure to Implement Comprehensive Care Plan for Constipation Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple medical issues, including advanced Alzheimer's, chronic constipation, and abdominal pain. Despite the resident's physician orders for various bowel medications and interventions, the care plan did not address these needs. The facility's policies required a person-centered care plan that included goals, outcomes, and interventions, but this was not reflected in the resident's care plan. The resident was admitted with several diagnoses, including sepsis, acute renal failure, and hypertension, and was receiving multiple medications for constipation. The resident's medical records indicated a history of chronic constipation and abdominal distention, yet the care plan did not include these issues or the interventions being used, such as the insertion of a Foley catheter for gas relief. Interviews with facility staff, including the Nurse Practitioner and Nurse Manager, confirmed the resident's ongoing issues with constipation and abdominal discomfort, and the use of bowel medications and rectal interventions. The Director of Nurses acknowledged that the resident's care plan was incomplete and did not include the necessary interventions for constipation and abdominal pain. The DON stated that it was the responsibility of the nursing staff, including the MDS Nurse and Nurse Unit Managers, to ensure that care plans are accurate and up-to-date. However, the care plan failed to reflect the resident's medical needs and the interventions being implemented, leading to a deficiency in the facility's care planning process.
Nursing Staff Competency Deficiency in Rectal Tube Procedure
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the process of inserting a rectal tube, as evidenced by the handling of a case involving a resident with a history of constipation and abdominal distention. The resident had a physician's order for a rectal tube insertion, but due to the unavailability of rectal tubes, an 18 French Foley Catheter was used instead. The Charge Nurse, who was unfamiliar with the procedure and had not reviewed the facility's policy, performed the insertion with assistance from a Nurse Practitioner. The facility did not stock rectal tubes, and the Charge Nurse did not document the procedure, relying on the Nurse Practitioner to do so. Further interviews revealed that other nursing staff, including Nurse #1 and Nurse #2, were also unfamiliar with the procedure and the facility's policy on rectal tube insertion and removal. They confirmed that the facility did not have rectal tubes in supply and used Foley Catheters as a substitute. Nurse #1 admitted to not consulting with other nurses or reviewing the policy before performing the procedure. There was a lack of documentation in the resident's progress notes regarding the insertion and removal of the Foley Catheter, as well as the resident's response to the procedure. The Staff Development Coordinator acknowledged that the facility had not provided education or skills training related to rectal tubes, despite having a policy in place. The Director of Nurses confirmed the existence of the policy and the expectation for nursing staff to be knowledgeable about it and document procedures performed. However, the facility's failure to stock rectal tubes and the lack of documentation and training contributed to the deficiency in care provided to the resident.
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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