Life Care Center Of The North Shore
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynn, Massachusetts.
- Location
- 111 Birch Street, Lynn, Massachusetts 01902
- CMS Provider Number
- 225529
- Inspections on file
- 19
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of The North Shore during CMS and state inspections, most recent first.
Surveyors observed that food was not consistently served at safe or appetizing temperatures, with hot foods often below 120°F and cold foods above 50°F. Multiple residents reported dissatisfaction with the temperature and taste of meals, and test tray audits confirmed that food was frequently served outside the facility's required temperature ranges.
Surveyors identified improper food storage and labeling practices, including raw chicken stored above ready-to-eat foods and multiple open, undated food items in both the main kitchen and unit kitchenettes. Staff interviews confirmed these actions were not consistent with facility policy, which requires proper dating and storage of all food items and removal of expired products.
During a GI outbreak, the facility did not notify the physician of changes in condition for three residents who experienced symptoms such as vomiting, diarrhea, and significant weight loss. Despite facility policy requiring prompt notification, there was no documentation that the physician or NP was informed, and interviews with staff confirmed a lack of awareness and communication regarding the outbreak and affected residents.
During a GI outbreak, the facility did not document symptoms for most affected residents, despite staff expectations and facility policy. Additionally, a resident with a dialysis fistula had repeated inaccurate documentation of blood pressure readings, with records showing use of the left arm when only the right arm was used, contrary to physician orders.
The facility failed to ensure a dignified existence for three residents by not assisting with the removal of unwanted chin hair. Residents with moderate cognitive impairment and various medical conditions were observed with significant chin hair and expressed a desire to have it removed. Staff confirmed it was their responsibility to assist, but this was not done, and care plans did not indicate any refusal of care.
The facility failed to ensure that two residents were free from physical restraints. Pillows were placed under the fitted sheets to prevent the residents from climbing out of bed, effectively acting as restraints. The facility did not have proper assessments, consents, or physician's orders for these restraints, and the care plans did not address their use.
The facility failed to communicate the appropriate diet and assess the diet texture for a resident upon readmission from a hospital stay. The resident, with a history of dysphagia and other conditions, was readmitted with a regular diet order instead of the previously prescribed Regular Easy to Chew (ETC) diet. Observations and staff interviews confirmed that the resident struggled with food preparation and required a speech therapy assessment, which was not conducted.
A facility failed to follow a physician's order for a resident with moderate cognitive impairment and swelling in the lower right leg. The resident was observed multiple times wearing non-skid socks instead of the prescribed TED stockings. A nurse confirmed the oversight and noted that the night shift was responsible for putting on the stockings.
The facility failed to provide necessary treatment and services to prevent and manage pressure ulcers for two residents. One resident developed a stage 2 pressure ulcer due to lack of preventative interventions upon admission, while another resident did not receive ordered Prevalon heel boots, leading to redness and non-blanchable discoloration on the heels.
The facility failed to properly label medications and store treatment items separately from oral medications in one of three medication carts. An open Arnuity inhaler without a date, Calamine lotion, Tucks pads, and Preparation H cream were found stored together. A nurse was unable to locate the date the inhaler was opened, contrary to manufacturer guidelines.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food that was palatable and at a safe and appetizing temperature across all three units. The facility's own Test Tray Audit form specified that hot foods should be above 120°F, cold foods below 50°F, and trays should be served within 15-20 minutes. However, multiple residents voiced dissatisfaction with the temperature and taste of the food, with several stating that food was often cold when delivered. During test tray audits, food items such as cream of wheat, scrambled eggs, toast, and hashbrowns were consistently served below the required hot food temperature, and cold items like milk and juice were often above the required cold food temperature. Additionally, food was observed to be served on paper products in one unit due to a Norovirus outbreak. The Food Service Director confirmed that her expectations for food temperature and serving times matched the facility's policy, and the Registered Dietitian stated that hot food should be at least 140°F when served. Despite these expectations, observations showed that food was not consistently served within the required temperature ranges or timeframes, and residents reported dissatisfaction with both the temperature and palatability of the meals provided.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple observations of improper food storage and labeling practices in the main kitchen and unit kitchenettes. Specifically, raw chicken was stored on the top tray of a rack in the walk-in refrigerator above cooked pork and ready-to-eat deli meat, with the chicken bags open and undated. Additionally, several food items in the walk-in and reach-in refrigerators, such as sandwiches, shredded cheese, fried food, pasta salad, American cheese, salami, deli turkey, and various juices, were found open and undated. In the unit kitchenettes, similar issues were observed, including undated open juices, undated cooked salami, undated egg salad sandwiches, and leftover food containers without dates or proper labeling. Expired milk was also found in one kitchenette refrigerator. Interviews with staff confirmed that these practices were not in line with facility policy, which requires all open and prepared food items to be dated and stored properly, with raw foods kept below ready-to-eat foods. The Assistant Food Service Director acknowledged that raw chicken should not have been stored above cooked pork, and the Food Service Director stated that all undated and expired foods should be discarded. A Certified Nursing Aide also noted that expired milk should have been removed from the refrigerator, as the kitchen staff is responsible for daily checks and organization.
Failure to Notify Physician of Change in Condition During GI Outbreak
Penalty
Summary
The facility failed to notify the physician of a change in condition for three residents during a gastrointestinal (GI) outbreak, as required by facility policy. Nineteen residents were identified as having GI symptoms such as abdominal pain, diarrhea, and vomiting, with the earliest onset recorded on 3/19/25. For three residents, there was no documentation that the physician was notified of their change in condition, despite the presence of significant symptoms and, in one case, notable weight loss. One resident with dementia, stroke, and diabetes, who was dependent for all care, experienced vomiting and diarrhea over several days, but there was no evidence in the nursing progress notes that the physician was informed. Another resident, cognitively intact but dependent for care, had vomiting and diarrhea and received Pepto-Bismol, yet again, there was no documentation of physician notification. A third resident, also cognitively intact and requiring moderate assistance, exhibited GI symptoms and lost seven pounds in one day, but the physician was not notified of either the symptoms or the weight loss. Interviews with the Medical Director, MDS Coordinator, Infection Preventionist, and DON confirmed that neither the Medical Director nor the Nurse Practitioner was notified of the outbreak or the residents' symptoms. Staff interviews revealed a lack of awareness regarding the need for physician notification and documentation during such outbreaks, and the DON was unaware of the extent of the documentation gaps and the significant weight loss experienced by one resident.
Failure to Maintain Accurate Medical Records During GI Outbreak and for Dialysis Patient
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents during a gastrointestinal (GI) outbreak and for a resident with specific blood pressure monitoring requirements. During a Norovirus outbreak on the Garden View Unit, 19 residents were identified as having GI symptoms such as nausea, vomiting, and diarrhea. However, review of medical records showed that for 16 of these residents, there was no documentation of their GI symptoms. Multiple staff interviews confirmed that nursing staff did not document symptoms, assessments, or interventions related to the GI illness, despite facility policy and staff expectations that such changes in condition should be recorded in the medical record. Additionally, for a resident with end stage renal disease and a dialysis fistula in the left arm, nursing documentation repeatedly indicated that blood pressure readings were taken from the left arm, contrary to physician orders. Interviews with the resident and staff revealed that only the right arm was used for blood pressure readings, and the documentation of left arm use was inaccurate. The DON confirmed that accurate documentation of which arm was used is expected.
Failure to Assist with Removal of Unwanted Chin Hair
Penalty
Summary
The facility failed to ensure a dignified existence for three residents by not assisting with the removal of unwanted chin hair. Resident #23, who has a traumatic brain injury and moderate cognitive impairment, was observed multiple times with significant chin hair. The resident expressed embarrassment and stated that staff did not offer to remove the hair. Both a CNA and a nurse confirmed that it is the responsibility of CNAs to remove unwanted chin hair during morning care, but this was not done for Resident #23. The resident's care plan and progress notes did not indicate any refusal of care, highlighting a lapse in personal hygiene assistance. Similarly, Resident #45, who has osteoarthritis, weakness, and depression, and also has moderate cognitive impairment, was observed with significant chin hair on multiple occasions. The resident expressed a desire to have the hair removed and mentioned that usually, his/her daughter would do it, but staff had not offered to assist. Resident #97, admitted with drug-induced polyneuropathy and muscle weakness, was also observed with thick facial hair on several occasions. The resident expressed a desire to have the hair removed, and a CNA confirmed that it is their responsibility to offer shaving during morning care. The medical record for Resident #97 did not indicate any refusal of care, further emphasizing the facility's failure to assist with personal hygiene.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, Resident #81 and Resident #102, were free from the use of physical restraints. Resident #81, who has severe cognitive impairment and requires substantial assistance for bed mobility, was observed with pillows placed under the fitted sheet on both sides of the bed. This was done by the night staff to prevent the resident from climbing out of bed, effectively acting as a restraint. The facility did not have an assessment, consent, or physician's order for the use of these restraints, and the care plan did not address the use of restraints or the placement of pillows under the fitted sheet. Similarly, Resident #102, who has moderately impaired cognition and is at high risk for falls, was observed with a pillow tucked under the fitted sheet on the right side of the bed. This was done to prevent the resident from climbing out of bed, as the resident has a behavior of kicking legs and attempting to get out of bed. The facility also failed to have an assessment, consent, or physician's order for the use of this restraint, and the care plan did not address the use of restraints. Interviews with CNAs and nurses confirmed that the pillows were placed under the fitted sheets to prevent the residents from getting out of bed, effectively acting as restraints. The Director of Nursing stated that the facility is supposed to be restraint-free and that staff should not be using pillows in this manner without proper assessment and documentation.
Failure to Communicate and Assess Appropriate Diet for Resident
Penalty
Summary
The facility failed to meet professional standards of quality for one resident, specifically by not communicating the appropriate diet and failing to assess the diet texture upon readmission from a hospital stay. Resident #8, who had a history of anoxic brain injury, dysphagia, and other conditions, was readmitted to the facility with a diet order of a regular diet, despite previously being on a Regular Easy to Chew (ETC) diet. The transfer form to the hospital did not indicate the resident's therapeutic diet, and upon readmission, the resident was not reassessed by speech therapy to confirm the appropriate diet texture. Observations revealed that Resident #8 struggled to cut food and was not using a lip plate, which was part of the dietary recommendations. Signs indicating the need for food to be cut into bite-sized pieces were present, but the resident was still observed eating whole sausages and other foods that were not appropriately prepared. Interviews with staff confirmed that the resident had a history of choking and required food to be cut up, and that a speech therapy assessment was necessary to upgrade the diet from Regular ETC to a regular diet. The Director of Nursing (DON) acknowledged that the readmission paperwork should have been reviewed to ensure accuracy and that a speech evaluation should have been completed upon the resident's return from the hospital. The DON and the Director of Rehabilitation (DOR) both confirmed that the resident was not evaluated in the hospital or the facility after the initial speech therapy assessment, leading to the deficiency in providing the appropriate diet and necessary assessments for Resident #8.
Failure to Follow Physician's Order for TED Stockings
Penalty
Summary
The facility failed to follow a physician's order for a resident who was admitted with diagnoses including hyperlipidemia and dementia. The resident, who has moderate cognitive impairment and requires assistance with lower body dressing, had an order for TED stockings to be worn in the morning and removed in the evening. However, during multiple observations over three consecutive days, the resident was found wearing non-skid socks instead of the prescribed TED stockings, and exhibited swelling in the lower right leg. A nurse confirmed that the resident should have been wearing the TED stockings as per the physician's order and indicated that the night shift was responsible for putting them on when the resident gets up.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to ensure that two residents received necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. For one resident, who was totally dependent on staff and at high risk for pressure ulcers, the facility did not implement interventions to prevent pressure ulcer development upon admission. This resident developed a stage 2 pressure ulcer within 24 days of admission. The resident's clinical record indicated multiple skin issues upon readmission, but no skin care plan or interventions were put in place until after the pressure ulcer developed. The Wound Nurse and Director of Nursing Services acknowledged that preventative measures should have been implemented at the time of admission and reviewed weekly to prevent worsening of the wounds. For another resident, the facility failed to implement Prevalon heel boots as ordered by the physician. This resident, who had moderate cognitive impairment and was at risk for developing pressure ulcers, was observed multiple times without the Prevalon heel boots while lying in bed. The resident's heels were directly placed on the mattress, leading to redness and non-blanchable discoloration. Despite the physician's order and documentation indicating that the boots were to be worn, the resident was not provided with the necessary protective equipment. Interviews with nursing staff and the Director of Nursing confirmed that physician orders should be followed as written. These deficiencies highlight the facility's failure to adhere to professional standards of practice in providing necessary treatment and services to prevent and manage pressure ulcers. The lack of timely interventions and failure to follow physician orders contributed to the development and worsening of pressure ulcers in these residents.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure medications were labeled properly and treatment items were not stored with oral medications in one of three medication carts observed. The facility's policy indicated that external use medications and biologicals should be stored separately from internal use medications and biologicals, and that opened medications should have the date of opening recorded if they have a shortened expiration date. During an observation, a surveyor found an open Arnuity inhaler without a date, a bottle of Calamine topical lotion, a box of Tucks hemorrhoidal pads, and a tube of Preparation H hemorrhoidal cream stored together in the Hillview medication cart. Nurse #5 was unable to locate the date when the inhaler was opened, which is against the manufacturer's directions to discard the inhaler 6 weeks after opening.
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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