Life Care Center Of Wilbraham
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilbraham, Massachusetts.
- Location
- 2399 Boston Road, Wilbraham, Massachusetts 01095
- CMS Provider Number
- 225543
- Inspections on file
- 16
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Wilbraham during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in three unit kitchenettes, with surveyors observing toasters laden with crumbs, dried food splatter in cabinets, and unclean refrigerators. The FSD and a dietary aide confirmed that daily cleaning was not occurring, potentially leading to foodborne illness concerns.
A LTC facility failed to adhere to infection control standards, affecting eight residents. Staff improperly used PPE, did not implement necessary precautions for residents with infections, and failed to maintain proper hand hygiene. These actions increased the risk of cross-contamination and infection transmission.
Two residents in a facility were unable to exercise their right to make medical decisions as their Health Care Proxies (HCPs) signed advanced directives and consent forms without being properly invoked. One resident, cognitively intact, had their MOLST form signed by an HCP due to a perceived language barrier, while another resident with severe cognitive impairment had their forms signed before HCP invocation, despite language and communication issues. Facility staff failed to document or communicate the need for HCP involvement appropriately.
The facility failed to respond promptly to call lights, affecting residents' needs and preferences. Several residents experienced long wait times for assistance, leading to incontinence and distress. Observations showed staff did not consistently adhere to the policy of answering call lights within five minutes, particularly during shift changes.
A facility failed to ensure a resident's advanced directives were fully implemented due to a Nurse Practitioner not signing all required areas of the MOLST form. The resident, with acute respiratory failure and COPD, had their health care proxy invoked, but the back page of the MOLST form, indicating no artificial nutrition, was not signed by the NP, rendering it invalid.
A facility failed to adhere to professional standards for a resident with a PICC line, resulting in inaccurate measurement and documentation of the external catheter length and arm circumference. The resident, with a history of severe infections, had discrepancies in recorded measurements, which were critical for ensuring the PICC line's correct placement. This failure placed the resident at risk for catheter-related complications.
The facility failed to adhere to professional standards of practice for skin care management for two residents. One resident, with severe cognitive impairment and on anticoagulant medication, had unexplained scabbed areas on the upper lip with no documentation or investigation conducted. Another resident, at risk for pressure ulcers, did not receive required weekly skin assessments for two weeks. These deficiencies indicate a lapse in the facility's care processes.
A facility failed to ensure necessary respiratory care for a resident using a CPAP machine with oxygen therapy. Despite the resident's care plan documenting the required settings, there were no physician's orders specifying the CPAP pressure settings or oxygen flow rate, as required by facility policy. Staff interviews confirmed the oversight, leading to a deficiency noted by surveyors.
A facility failed to ensure proper care for a resident on hemodialysis by not having a Physician's order for fluid restriction and not documenting the resident's fluid intake. The resident, with End Stage Renal Disease, lacked a documented fluid restriction order, and staff interviews confirmed the absence of daily fluid intake records, making it unclear how much fluid the resident consumed.
A facility failed to implement the Behavioral Health Care Team's recommendations for a resident on antipsychotic medication. The team advised conducting a lipid panel and HbgA1c test after three months of medication use, but these tests were not performed. The Behavioral Health Team's notes were sent to the resident's PCP, who did not order the tests, and facility staff did not ensure the recommendations were followed.
A facility failed to limit the timeframe for a PRN psychotropic medication to 14 days for a resident with Depression and Adjustment Disorder with Anxiety. The resident's Trazodone order, starting in February, lacked an end date and was administered beyond the 14-day limit without a physician's review. Staff interviews confirmed non-compliance with the policy requiring a stop date and physician review for continued use.
A facility failed to securely store medications when an Insulin Lispro Pen was left unattended on a medication cart in the hallway. The assigned nurse was on break, leaving the cart unsupervised for 19 minutes, during which a resident passed by. Nurse #4 later secured the pen, acknowledging the risk of leaving it unattended.
The facility failed to ensure the required members, specifically the DON and IP, were present at a QAPI meeting. The facility's policy requires the QAA Committee to include the DON, Medical Director, IP, and at least three other staff members, including the Administrator. The June 2024 meeting lacked evidence of the DON or IP's attendance, and no representative provided their reports.
The facility failed to provide Bed-Hold Notices to residents or their representatives upon hospital transfer, affecting multiple residents. Staff interviews revealed confusion over departmental responsibilities, leading to the oversight. This deficiency involved residents with conditions such as dementia and COPD.
Facility Fails to Maintain Sanitary Conditions in Unit Kitchenettes
Penalty
Summary
The facility failed to maintain three unit kitchenettes in a safe and sanitary condition, as observed by surveyors. In the Hampden Garden Unit kitchenette, a toaster was found laden with crumbs, and the inside of a cabinet storing snacks had dried dark brown splatter on the shelves and door. The [NAME] Terrace Unit kitchenette also had a toaster with crumbs and dried pieces of bread stuck inside, which the Food Service Director (FSD) acknowledged could pose a fire risk. Additionally, the refrigerator in the [NAME] Terrace Unit had dried yellow material on the floor. The Hampshire Woods Unit kitchenette had thick dried brown material on the refrigerator floor. During interviews, the FSD and Dietary Aide #1 confirmed that the kitchenettes should be cleaned daily, but this was not occurring. The FSD was unsure who was responsible for cleaning the toasters regularly, and Dietary Aide #1 stated that afternoon dietary aides were supposed to clean the kitchenettes while stocking snacks. The FSD acknowledged that the lack of cleaning could lead to foodborne illness concerns, as dried food or liquid materials were not being removed from the refrigerators and cabinets as required.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards on one of its units, affecting eight residents. For one resident, a nurse improperly donned a gown that touched the floor, failed to clean and disinfect a table before setting up treatment supplies, and used scissors that were not disinfected between uses, increasing the risk of contamination and infection. Another resident had dressing materials brought into their room that were then returned to the treatment cart, posing a risk of cross-contamination. In another case, a resident with suspected Clostridium Difficile (C. Diff) infection was not placed on Contact Precautions while awaiting test results, and the facility did not implement Special Contact/Droplet Precautions for two residents diagnosed with Influenza. Additionally, Enhanced Barrier Precautions were not implemented for two residents at high risk for contracting infections, and a resident diagnosed with C. Diff was not placed on Contact Plus Precautions. The facility's infection prevention and control program was found lacking in several areas, including the improper use of personal protective equipment (PPE), failure to implement appropriate transmission-based precautions, and inadequate hand hygiene practices. These deficiencies were observed during interactions with residents, where staff either did not follow proper procedures or were unaware of the necessary precautions, leading to potential cross-contamination and increased risk of infection transmission.
Failure to Invoke Health Care Proxies Appropriately
Penalty
Summary
The facility failed to ensure that two residents were able to exercise their right to make decisions regarding their medical care, as their Health Care Proxies (HCPs) were not invoked, yet the HCPs signed advanced directives and consent forms. For the first resident, who was admitted with a cerebrovascular accident and diabetes, the facility allowed the HCP to sign a Medical Order for Life-Sustaining Treatment (MOLST) form despite the resident being cognitively intact and able to communicate in English. The resident's clinical record did not indicate that the HCP was invoked, and the resident confirmed they could communicate their needs and had no difficulty with the staff. The second resident, admitted with cognitive communication deficit and dementia, had their MOLST form and consents for psychotropic medications and vaccinations signed by the HCP before the HCP was officially invoked. The resident was severely cognitively impaired and primarily spoke Portuguese, yet there was no documented evidence that the HCP was invoked due to language barriers. The resident's communication care plan did not reflect the need for HCP involvement, and the staff failed to provide information in the resident's native language before the HCP was invoked. Interviews with facility staff, including the Assistant Director of Nurses (ADON) and the Director of Nursing (DON), revealed that there was a lack of documentation and communication regarding the invocation of HCPs. The ADON acknowledged that if residents deferred to their HCPs for signing paperwork, there should be a note in the clinical record. The DON was made aware of the concerns regarding the improper signing of paperwork by HCPs without proper invocation.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs and preferences of several residents, as evidenced by delayed responses to call lights. Residents #98 and #75 reported waiting 15 to 30 minutes for assistance during early morning shift changes, leading to incidents of incontinence and increased anxiety. Resident #101 also experienced incontinence due to prolonged wait times for toileting assistance, a condition that was new since admission to the facility. These delays were particularly noted during shift changes and were corroborated by observations and resident interviews. On the [NAME] Terrace Unit, call lights were not answered promptly, with one instance where a call light remained on for eight minutes while staff passed by without responding. Another resident reported waiting an hour for assistance, and Resident #169's call light was observed to be lit for 19 minutes before a nurse responded. This resident required assistance with mobility and transfers due to a history of falls and muscle weakness, highlighting the critical need for timely staff response. Resident #72, who required assistance with personal care and toileting, was observed waiting for assistance for over 20 minutes, during which time the resident repeatedly called for help. Despite the call light being audible at the nursing station, staff did not respond promptly, resulting in the resident's distress. The facility's policy requires call lights to be answered within five minutes, yet observations and resident reports indicate this standard was not consistently met, contributing to the deficiencies noted in the survey.
Failure to Implement Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident had the opportunity to formulate advanced directives and that their wishes regarding these directives were implemented. Specifically, the deficiency involved a resident who was admitted with acute respiratory failure and chronic obstructive pulmonary disorder. The resident's health care proxy was invoked, and a Medical Order for Life Sustaining Treatment (MOLST) form was completed. However, the Nurse Practitioner (NP) did not sign all required areas of the MOLST form, specifically the back page, which indicated no artificial nutrition. During a review of the MOLST form, it was found that while the front page was signed by both the resident's health care proxy and the NP, the back page was only signed by the health care proxy. The absence of the NP's signature on the back page rendered it invalid, as confirmed by the Assistant Director of Nursing during an interview with the surveyor. This oversight resulted in the facility's failure to fully implement the resident's advanced directives as required by their policy.
Inaccurate PICC Line Measurements and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The deficiency involved the inaccurate measurement and documentation of the external catheter length and arm circumference for a resident receiving IV antibiotics. The facility's policy required accurate measurement of the external catheter length and arm circumference to ensure the PICC line had not migrated, which was not adhered to in this case. The resident, admitted with multiple diagnoses including Metabolic Encephalopathy, Sepsis, and MSSA infection, had a PICC line placed in the upper right extremity. The hospital records indicated the external catheter length was 2 cm, and the arm circumference was 36 cm at the time of insertion. However, facility records showed discrepancies in these measurements, with the external catheter length documented as 41 cm on one occasion and 4 cm on another, and the arm circumference documented as 36 cm initially and then 12 cm later. During the survey, the Assistant Director of Nurses (ADON) re-measured the resident's arm circumference and external catheter length, finding a significant difference from the initial measurements. The Infection Preventionist confirmed that the external catheter length was not consistent with the initial 2 cm measurement. The failure to accurately measure and document these parameters placed the resident at risk for potential catheter-related complications, as the PICC line's position in the superior vena cava was critical for safe medication administration.
Failure in Skin Care Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice related to skin care for two residents. For Resident #22, the facility did not identify a new skin alteration or conduct an investigation to determine its cause. The resident, who was severely cognitively impaired and on anticoagulant medication, was observed with bilateral scabbed areas on the upper lip. Despite multiple observations and interviews, there was no documentation in the resident's medical record regarding the origin or timing of these injuries. Staff members, including a CNA and a nurse, speculated that the injuries might have been caused by shaving, but no formal assessment or documentation was completed. For Resident #62, the facility failed to conduct weekly skin checks as required by the resident's comprehensive care plan. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, did not have documented weekly skin assessments for two consecutive weeks. The Director of Nursing confirmed that the assessments were not completed as scheduled, despite being set up in the electronic medical record system. This oversight left the resident without the necessary monitoring for potential skin integrity issues. The deficiencies highlight a lack of adherence to the facility's policy on basic skin management, which mandates regular skin inspections and prompt documentation of any changes. The failure to document and investigate skin alterations for Resident #22 and to perform scheduled skin assessments for Resident #62 indicates a gap in the facility's care processes, potentially compromising the residents' health and safety.
Lack of Physician's Orders for CPAP and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that necessary respiratory care and services were in place for a resident, specifically regarding the use of a Continuous Positive Airway Pressure (CPAP) machine and oxygen therapy. The resident, who was admitted with a diagnosis of Complex Sleep Apnea, was observed using a CPAP machine with oxygen every night. However, there were no physician's orders specifying the CPAP pressure settings or the oxygen flow rate, which are required according to the facility's policy. The resident's care plan did include these settings, but the absence of a formal physician's order constituted a deficiency. Interviews with nursing staff and the unit manager confirmed that the resident used the CPAP with oxygen nightly, and they acknowledged the lack of physician's orders for the CPAP settings and oxygen flow rate. The facility's policy mandates that such orders must be in place, including details like mode, pressure setting, mask type, and oxygen liters per minute. Despite the care plan documentation, the failure to have a physician's order in place for these treatments was a clear oversight, leading to the deficiency noted by the surveyors.
Failure to Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to implement professional standards of care for a resident requiring hemodialysis, specifically by not having a Physician's order for fluid restriction and not maintaining documentation of the resident's fluid intake. The resident, who was admitted with End Stage Renal Disease (ESRD) and received dialysis services three times a week, did not have a documented fluid restriction order in their March 2025 Physician's orders. Additionally, the resident's care plan encouraged fluid intake up to 1200 cc per day, but there was no evidence in the medical record that nursing staff documented the resident's daily fluid intake. Interviews with facility staff revealed that there was an expectation for a Physician's order to be in place for fluid restriction and for nursing staff to document daily fluid intake. However, both Nurse #6 and Unit Manager #1 confirmed that there was no documentation of the resident's fluid intake, making it unclear how much fluid the resident consumed each day. The Dialysis Unit Manager from the dialysis facility also indicated that the nursing facility should provide fluid intake information if requested, as it could be important for addressing unexpected weight changes in the resident.
Failure to Implement Behavioral Health Recommendations
Penalty
Summary
The facility failed to implement the recommendations made by the Behavioral Health Care Team for a resident diagnosed with multiple mental health disorders, including generalized anxiety disorder, psychotic disorder, depression, and dementia with psychosis. The resident was started on antipsychotic medication, and the Behavioral Health Physician Assistant recommended a lipid panel and Hemoglobin A1C (HbgA1c) lab work to be drawn after three months of medication use. However, the facility did not ensure these tests were conducted as recommended. Interviews with facility staff revealed that the Behavioral Health Team's notes and recommendations were faxed to the resident's Primary Care Provider (PCP), who was responsible for reviewing and implementing any necessary orders. Despite this process, there was no documentation indicating that the PCP ordered the recommended tests, and the facility staff did not verify whether the recommendations were followed. This oversight resulted in the failure to monitor the resident's health condition as advised by the Behavioral Health Team.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to the regulatory requirement of limiting the timeframe for a PRN psychotropic medication to 14 days for a resident. Specifically, the resident was admitted with diagnoses of Depression and Adjustment Disorder with Anxiety and had a physician's order for Trazodone, an antidepressant medication, to be administered as needed. The order, which began on February 23, 2025, did not include an end date, and the medication was administered on March 2 and March 10, 2025, exceeding the 14-day limit without a physician's review. Interviews with facility staff revealed a lack of compliance with the policy that requires PRN psychotropic medications to be reviewed and renewed by a physician after 14 days. Nurse #9 confirmed that such medications should have a stop date and require a physician's review for continued use. The Unit Manager acknowledged that the PRN order for Trazodone should have been reviewed by March 9, 2025, but was not, resulting in the deficiency.
Unattended Insulin Pen on Medication Cart
Penalty
Summary
The facility failed to ensure that medications were stored securely, as observed with the Hampden Garden Long Hall medication cart. An Insulin Lispro Pen was left unattended on top of the medication cart in the hallway, accessible to residents. This occurred when the nurse assigned to the cart left the floor for a break, leaving the cart unsupervised for approximately 19 minutes. During this time, a resident was observed wheeling past the unattended cart and into their room. Nurse #4, upon returning to the area, acknowledged that the Insulin Lispro Pen should not have been left unattended due to the risk of a resident taking it. The nurse then removed the pen to store it securely until the assigned nurse returned. The Assistant Director of Nursing confirmed that no medications should be left unsupervised on top of the medication cart, indicating a lapse in adherence to the facility's policy on medication storage.
QAPI Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members during one of the four quarterly meetings reviewed. Specifically, the Director of Nursing (DON) and the Infection Preventionist (IP) or a designated representative were not present at the June 2024 quarterly QAPI meeting. The facility's policy mandates that the QAA Committee must include the DON, the Medical Director or designee, the IP, and at least three other staff members, including the facility's Administrator. A review of the meeting attendance sign-in sheet for the QAPI meeting held on June 17, 2024, showed no evidence of the DON or IP's attendance. During an interview on March 12, 2025, the Administrator confirmed the absence of documented evidence that the DON or IP attended the June 2024 QAPI meeting. The Administrator acknowledged the requirement for the DON or IP to be present or for a representative to provide an updated report on their behalf to the QAPI committee. However, there was no documented evidence that such reports were presented by a designee as required.
Failure to Provide Bed-Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a Notice of Bed-Hold Policy and Return in writing to residents or their representatives upon transfer to the hospital. This deficiency was identified for two residents out of a sample of 22 and one resident out of three closed records reviewed. The facility's policy requires that the Bed-Hold policy be given upon admission and upon transfer to the hospital, ensuring residents and their representatives are informed about the bed-hold and reserve bed payment policy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of the affected residents. Interviews with facility staff revealed a lack of clarity and responsibility regarding who was tasked with providing the Bed-Hold Notices. The Admissions Assistant, Social Worker, and Business Office Manager each believed that another department was responsible for sending out these notices. Consequently, no department took responsibility, resulting in the failure to provide the necessary documentation to the residents' representatives. This oversight affected residents with various medical conditions, including dementia, COPD, and influenza, who were transferred to the hospital without the required notification being issued.
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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