Lighthouse Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Revere, Massachusetts.
- Location
- 204 Proctor Avenue, Revere, Massachusetts 02151
- CMS Provider Number
- 225297
- Inspections on file
- 14
- Latest survey
- February 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lighthouse Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not submit direct care staffing data to CMS for FY Quarter 4 2024. The Administrator, who joined in November 2024, was aware of the issue, which occurred under previous ownership. The Regional Administrator confirmed the facility's acquisition by a new company in October 2024 and the inability to obtain staffing data from the former owner, leading to the non-submission.
The facility failed to report allegations of abuse, neglect, or injuries of unknown origin to the State Agency within the required timeframe for three residents. One resident's X-ray showed rib fractures of unknown origin, another had an acute fracture, and a third alleged neglect when staff refused assistance. Delays in reporting were due to issues with the Health Care Facility Reporting System and miscommunication among staff.
The facility exceeded the acceptable medication error rate, with errors involving incorrect dosing, crushing of extended-release tablets, and administration of expired medication. A resident received an incorrect dose of Fluticasone, another had a metoprolol tablet crushed against guidelines, and a third was given expired calcium with vitamin D instead of the prescribed form.
The facility failed to secure medication carts and properly label and store medications. Unlocked and unattended carts were found on two units, with unlabeled medication cups accessible. Opened and undated medications, including eye drops, inhalers, and insulin, were observed, contrary to facility policy. Nursing staff acknowledged responsibility for these lapses.
The facility failed to store food according to professional standards, as observed in three unit kitchenette refrigerators. Items such as a nutritionally fortified shake, hot dogs, baked beans, and spreadable cheese were found undated. Additionally, apple juice and orange juice were past their use-by dates or undated, and a slice of pizza and sharp white cheddar cheese were improperly labeled. The Food Service Director acknowledged that food should be labeled, dated, and discarded after specific periods, which was not adhered to.
The facility failed to ensure nursing staff completed the required 12 hours of annual training, including dementia training, for 4 out of 5 employee records reviewed. The Director of Nursing reported that access to the education system was lost when a new company took over, resulting in the inability to verify training completion.
A resident with severe cognitive impairment and physical limitations was not provided a dignified dining experience, as staff stood while feeding instead of sitting at eye level, contrary to the facility's dignity policy. This was observed over several days, and the ADON acknowledged the issue, instructing CNAs to sit while feeding.
The facility did not secure resident PHI on two nursing units. An unattended medication cart on the third-floor unit had an open computer displaying a resident's name and medications. Similarly, an unattended nursing laptop in the first-floor common area showed a resident's name, date of birth, and medication information. Both Nurse #5 and the DON acknowledged that such information should not be left visible when unattended.
A facility failed to conduct a restraint assessment before applying an air mattress with bolsters for a resident with dementia, who was dependent on assistance for movement. The mattress was used as a fall intervention after the resident's recent hospitalization and fall, but staff did not complete the required assessment to justify its use as a restraint.
Two residents in an LTC facility experienced injuries of unknown origin, including rib and hip fractures, which were not reported to facility administration immediately as required by policy. The delay in reporting these injuries highlights lapses in communication and adherence to protocols, impacting resident safety and regulatory compliance.
A resident with cognitive impairment and mobility issues sustained a fracture, but the facility failed to conduct a thorough investigation. The investigation did not include interviews with all staff who had contact with the resident, contrary to facility policy. The incident report concluded the fracture occurred during a self-transfer, but this was determined without comprehensive input from all relevant staff.
A facility failed to clarify conflicting physician's orders for a resident's suprapubic catheter flushes, leading to inconsistent care. The resident, who was cognitively intact, had orders for both three times daily and twice daily flushes. Nursing staff followed different schedules based on these orders, and the Unit Manager did not discontinue the previous order after the resident requested a reduction in flush frequency. The DON acknowledged the need for order clarification.
A resident was discharged without a complete discharge summary, as required by the facility's policy. The discharge note was not written, and the recapitulation of the resident's stay was left blank. The resident had been admitted with a wrist fracture and a stage 3 pressure ulcer. The DON acknowledged the oversight, noting that the resident was part of a community-based program.
The facility failed to assist three residents with activities of daily living (ADLs) and meal supervision. A resident with limited mobility had untrimmed nails and facial hair, despite expressing a desire for grooming. Another resident with dysphagia was left unsupervised during meals, contrary to physician orders for aspiration precautions. A third resident with cognitive impairment had long, dirty fingernails, indicating a lack of grooming assistance. Staff interviews confirmed the need for assistance, but it was not provided.
A resident with Bosnian as their primary language was not provided with necessary communication services, despite facility policies. Staff failed to use interpreter services or communication boards, leading to ineffective communication. Observations showed staff interacting in English, which the resident did not understand, and interviews confirmed the lack of adherence to the care plan.
A facility failed to implement contracture management interventions for a resident with Alzheimer's and lack of coordination by not ensuring the use of palm protectors. Despite recommendations and staff education in December, the order was not entered into the medical record until February, and observations confirmed the absence of palm protectors. Interviews revealed communication gaps in documenting and executing the order.
A facility failed to implement a physician-ordered intervention for a resident with Alzheimer's and a history of falls. Despite a physician's order for a fall mat to be placed on the window side of the bed following an unwitnessed fall, observations during a survey revealed the mat was not in place. The resident's care plan and treatment records inaccurately documented the mat's presence, and staff interviews confirmed the oversight.
The facility failed to ensure the correct catheter size for two residents. One resident had a discrepancy between the hospital discharge summary and the physician's order for a Foley catheter, while another resident had an incorrect size suprapubic tube inserted due to a nurse not verifying the physician's order. Both residents were cognitively intact and required catheters due to medical conditions.
A facility failed to provide adequate fluid intake for a resident with vascular dementia, diabetes, and chronic kidney disease. The resident's physician ordered a free water bolus (FWB) of 175 mL every 4 hours, but nursing staff administered it only once per shift, resulting in insufficient daily fluid intake. The Unit Manager confirmed the order was not transcribed correctly, and the Dietitian highlighted the importance of the FWB for hydration.
A resident with chronic obstructive pulmonary disease required continuous oxygen therapy, but the facility failed to change the oxygen tubing weekly as ordered by the physician. Observations showed the tubing was not changed since December, despite the facility's policy and physician's orders. Interviews with staff confirmed the oversight, and the resident expressed concerns about the tubing length and inability to change it independently.
A nurse in an LTC facility failed to follow the medication administration policy by preparing medications from memory without verifying the MAR, leading to discrepancies in medication administration for a resident with epilepsy, diabetes, and heart failure. The nurse had signed off medications as administered before actually administering them, as confirmed by facility management.
The facility failed to accurately document care for two residents. One resident, with Alzheimer's and a history of falls, was documented to have a fall mat in place, which was not observed during multiple checks. Another resident, requiring hemodialysis, had blood pressure readings inaccurately recorded as taken from the left arm, despite orders against it due to a dialysis fistula. Staff interviews confirmed these documentation errors.
The facility did not notify the State Agency of a change in the Administrator, as required. The HCFRS lacked documentation of the notification, and interviews revealed that the DON believed the notification had been made, while the Administrator was unaware of the oversight.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 4 2024, which spans from July 1 to September 30. During an interview, the facility Administrator, who started in November 2024, acknowledged the lack of submission for the previous quarter's staffing data. He noted that the facility was under different ownership at that time. Additionally, the Regional Administrator confirmed that the facility was acquired by a new company in October 2024, and they were unable to obtain the necessary staffing data from the previous owner, resulting in the failure to submit the required information to CMS.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse, neglect, or injuries of unknown origin to the State Agency within the required timeframe for three residents. For one resident, the facility did not report an X-ray indicating multilevel right rib fractures of unknown origin within two hours. The Assistant Director of Nurses was aware of the fractures but did not report them immediately due to issues with the Health Care Facility Reporting System login and failed to notify the Director of Nurses promptly. The Director of Nurses was informed two days later and reported the injury to the state agency, but this was outside the required two-hour window. Another resident experienced an acute right intertrochanteric fracture, which was not reported to the state agency within the mandated two-hour period. The fracture was identified through a radiology report, and although the Director of Nursing was informed the following morning, the report to the state agency was delayed by several days. The incident report inaccurately stated that the Director of Nursing was notified earlier than she was, contributing to the delay in reporting. A third resident alleged neglect when a staff member refused to assist them in getting up from bed, despite the resident experiencing back pain and being unable to do so independently. The resident's allegation was not reported to the state agency within two hours, as required. Instead, the facility filed a grievance, and the allegation was not reported until 29 hours after the administrator was made aware. Interviews with staff revealed a lack of immediate concern for neglect, and the investigation into the allegation was not concluded promptly.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of 33 opportunities, resulting in a 9.09% error rate. For one resident, a nurse administered an incorrect dose of Fluticasone nasal spray, deviating from the physician's order of two sprays per nostril. Another resident received a crushed metoprolol extended-release tablet, contrary to the manufacturer's instructions to swallow whole, which was acknowledged by the administering nurse as a mistake. Additionally, a third resident was given an incorrect and expired medication. The nurse administered one tablet of calcium with vitamin D instead of the prescribed calcium carbonate tablet, and failed to verify the expiration date, which had passed. The Director of Nursing confirmed that the nursing staff should verify the correct dose, follow manufacturer guidelines, and check expiration dates before administering medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with acceptable professional standards of practice. On two separate units, medication carts were found unlocked and unattended, allowing unauthorized access. Nurse #1 and Nurse #2 both acknowledged that the medication carts should always be locked when unattended. Additionally, the surveyor observed unlabeled cups filled with pills in an unlocked cart, and Nurse #1 was unable to identify the intended recipients of two of the three cups. The Director of Nursing confirmed that the medication carts should be locked when unattended and that pre-pouring medication is not acceptable. Furthermore, the facility did not adhere to proper medication labeling and storage guidelines. Multiple opened and undated medications, including eye drops, inhalers, and insulin pens, were found on the medication carts. The facility's policy requires that multi-dose vials be dated once opened and discarded within 28 days unless otherwise specified by the manufacturer. The Nursing Supervisor and Nurse #1 acknowledged that nursing staff are responsible for dating medications and ensuring they are stored according to the manufacturer's guidelines. The Director of Nursing confirmed that medications should be stored according to these guidelines.
Failure to Properly Date and Store Food in Kitchenette Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed by the surveyor. In the first-floor kitchenette refrigerator, several items were found undated, including a bottle of a nutritionally fortified supplemental shake, a white plastic bag containing an open package of hot dogs and a plastic container of baked beans, and a container of spreadable cheese. Additionally, a pitcher of apple juice was dated 2/4 with a use-by date of 2/10, indicating it was past the recommended discard date. Similar issues were observed in the second-floor kitchenette refrigerator, where a pitcher of apple juice was undated, a single-serve bottle of orange juice was open with a straw inside and had an expiration date of 1/24/25, and a slice of pizza was wrapped in tin foil labeled with a resident room number but undated. A container of resident food was dated 2/7 and 2/9, and a package of sharp white cheddar cheese was opened, labeled with a resident room number but undated. On the third floor, the surveyor found a pitcher filled with orange juice dated 2/4 with a use-by date of 2/10, a resealable bag containing hard-boiled eggs undated, and another pitcher filled with apple juice undated. During an interview, the Food Service Director (FSD) stated that kitchenette refrigerators should be checked daily for label dates and expiration dates, and that food should be labeled, dated, and discarded after three days, while juice should be discarded after five days. The FSD also mentioned that any unlabeled food or juice should be discarded, indicating a failure to adhere to these standards in practice, as evidenced by the surveyor's findings.
Failure to Complete Required Annual Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the required 12 hours of annual training, including dementia training, for 4 out of 5 employee records reviewed. The facility's policy on staff education and competency outlines the importance of education in providing quality care, with training provided through various formats such as online resources and group sessions. Despite these policies, a review of 5 employee records, including 2 nurses and 3 Certified Nursing Assistants, revealed that none had completed the necessary annual training for the past year. During an interview, the Director of Nursing (DON) explained that the facility lost access to their education system, including proof of staff training and competency, when a new company took over in the Fall. This loss of access resulted in the inability to verify the completion of required training hours, particularly dementia training, for 4 out of the 5 employee records reviewed. The deficiency highlights a lapse in maintaining training records and ensuring compliance with annual training requirements.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #110, who is dependent on staff for feeding due to severe cognitive impairment and physical limitations, including Alzheimer's disease and hemiplegia. Observations by the surveyor on multiple occasions revealed that staff members stood beside the resident's bed, looking down while feeding, rather than sitting at eye level as required by the facility's dignity policy. This practice was observed over several days, indicating a consistent failure to adhere to the policy that promotes a dignified existence for residents. The facility's policy on dignity, dated February 2021, emphasizes the importance of caring for residents in a manner that enhances their well-being and self-esteem, including providing a dignified dining experience. Despite this, the care plan for Resident #110, who prefers to eat in their bedroom and is dependent on staff for all activities of daily living, was not followed appropriately. The Assistant Director of Nursing acknowledged the issue during an interview and observation, instructing the CNAs to sit while feeding the residents, highlighting a lapse in the implementation of the facility's dignity policy.
Failure to Secure Resident PHI on Nursing Units
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on two of its three nursing units. On the third-floor unit, a surveyor observed an unattended medication cart with an open computer displaying a resident's name and a list of medications. Nurse #5 acknowledged that the computer screen should not have been left open and unattended. Similarly, on the first-floor unit, an unattended nursing laptop in the common area was observed with an open screen showing a resident's name, date of birth, and medication information, visible to passersby. The Director of Nursing confirmed that computers with resident information should be shut down or put to sleep when not in use.
Failure to Conduct Restraint Assessment for Air Mattress with Bolsters
Penalty
Summary
The facility failed to complete a restraint assessment for a resident before applying an air mattress with bolsters, which is considered a physical restraint. The facility's policy requires a pre-restraining assessment to determine the need for restraints and to explore less restrictive interventions. However, this assessment was not conducted for the resident, who was observed with an air mattress with bolsters in place. The resident, diagnosed with dementia and dependent on assistance for movement, was seen wiggling with legs over the bolsters, indicating the use of the mattress as a restraint to prevent falls. Interviews with facility staff, including a CNA, Unit Manager, and the Assistant Director of Nurses, confirmed that the air mattress with bolsters was implemented as a fall intervention without a prior written restraint assessment. The resident had recently been hospitalized and experienced a fall upon returning to the facility, prompting the use of the mattress. Despite the staff's acknowledgment of the resident's ability to place their legs over the bolsters, the necessary assessment to justify the restraint was not completed, as confirmed by the Director of Nurses.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents, leading to a deficiency in their abuse policy implementation. Resident #87, who was admitted with dementia, had an X-ray on January 21, 2025, revealing multilevel right rib fractures of unknown origin. The Assistant Director of Nurses (ADON) was informed of the results but did not notify the Director of Nurses (DON) immediately, as required by the facility's policy. The notification to the DON was delayed until January 23, 2025, which was not in compliance with the policy that mandates immediate reporting of such injuries. Resident #118, admitted with ataxia, vascular dementia, and cognitive communication deficit, experienced new right leg pain on January 4, 2025. Despite the pain and subsequent X-ray revealing an acute right intertrochanteric fracture, the facility administration was not notified immediately. The fracture was discovered on January 5, 2025, but the DON was not informed until January 6, 2025, at 8:30 A.M. The incident report inaccurately stated that the DON was notified on January 5, 2025, at 7:00 P.M., which the DON later clarified was incorrect. The facility's failure to adhere to its policy for reporting injuries of unknown origin resulted in a delay in notifying the appropriate authorities and facility administration. This deficiency highlights lapses in communication and adherence to established protocols, which are critical for ensuring resident safety and compliance with regulatory requirements.
Incomplete Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who experienced a fracture. The resident, admitted in December 2024 with conditions including ataxia, vascular dementia, and cognitive communication deficit, was found to have an acute right intertrochanteric fracture. Despite the resident's moderate cognitive impairment and need for assistance with transfers, the facility did not conduct comprehensive interviews with all staff members who had contact with the resident during the period of the alleged incident. The investigation into the resident's injury was incomplete, as it did not include interviews with Certified Nurse Assistants or other staff members who provided direct care to the resident. The Director of Nursing and Assistant Director of Nursing only obtained statements from two nurses and a unit manager, failing to gather information from all relevant personnel. This lack of thorough investigation was contrary to the facility's policy, which requires interviews with all staff members on all shifts who had contact with the resident during the period of the alleged incident. The incident report concluded that the resident did not fall but may have sustained the fracture during a self-transfer when they plopped down hard into a chair. However, this conclusion was reached without comprehensive input from all staff involved in the resident's care. The facility's failure to conduct a thorough investigation and obtain statements from all relevant staff members led to a deficiency in addressing the injury of unknown origin adequately.
Failure to Clarify Conflicting Orders for Catheter Flushes
Penalty
Summary
The facility failed to meet professional standards of practice for a resident who required suprapubic catheter (SPT) flushes. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder, diabetes, and depression, had conflicting physician's orders for SPT flushes. One order, dated December 7, 2024, instructed the SPT to be flushed three times daily, while another order, dated January 24, 2025, instructed the SPT to be flushed twice daily. This discrepancy was not clarified by the nursing staff, leading to inconsistent administration of the flushes. Interviews with nursing staff revealed that they followed different schedules for flushing the SPT, based on their interpretation of the orders. The Unit Manager acknowledged that the resident had requested a reduction in the frequency of flushes, and the provider had agreed, but the previous order was not discontinued. The Director of Nursing confirmed that the nursing staff should have clarified the conflicting orders to ensure proper care for the resident.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as Resident #123, who was discharged from the facility. The discharge summary was supposed to include a recapitulation of the resident's stay, detailing their course of illness and treatment, as per the facility's policy revised in October 2022. However, upon review of the resident's electronic and paper medical records, it was found that the discharge note was not written, and the discharge summary was incomplete. Specifically, the sections titled 'Recapitulation of stay' and 'Social Service' were left blank. Resident #123 had been admitted to the facility with diagnoses including a fracture of the right wrist and a stage 3 pressure ulcer of the sacral region. The resident was discharged with a notice indicating that their health had improved sufficiently, negating the need for continued services at the facility. During interviews, the Director of Nursing acknowledged that a discharge note and a complete discharge summary should have been prepared, despite the resident being part of a community-based program that managed their stay and discharge decisions.
Failure to Assist Residents with ADLs and Meal Supervision
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in grooming and meal supervision. Resident #61, who was cognitively intact but dependent on staff for personal hygiene due to limited mobility, was observed with elongated fingernails and chin hair, indicating a lack of grooming assistance. Despite the resident's expressed desire to have their nails and facial hair cut, and the acknowledgment by staff that grooming should be offered daily, there was no documentation of refusal of care, suggesting a failure in providing the required assistance. Resident #15, who had a history of dysphagia and was on aspiration precautions, required supervision during meals to prevent aspiration. However, the resident was repeatedly observed eating alone in their room without staff supervision, despite physician orders and care plan requirements for 1:1 feeding at mealtimes. Staff interviews confirmed the necessity of supervision due to the resident's history of pneumonia and aspiration risks, yet the resident was left unsupervised, indicating a significant oversight in care. Resident #48, with severe cognitive impairment and dependent on staff for personal hygiene, was observed with long, dirty fingernails. The resident expressed a desire to have their nails cut, but staff failed to provide the necessary assistance. Interviews with nursing staff confirmed that the resident did not refuse care and required help with grooming, yet the assistance was not provided, highlighting a deficiency in meeting the resident's ADL needs.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication services for Resident #15, who was admitted with diagnoses including dysphagia, muscle weakness, chronic kidney disease, and major depressive disorder. The resident's preferred language is Bosnian, and they require an interpreter to communicate effectively with healthcare staff. Despite the facility's policy to ensure communication for non-English speaking residents, observations revealed that staff did not utilize interpreter services or communication boards as outlined in the resident's care plan. During multiple observations, staff members were seen interacting with Resident #15 without using the required communication aids. Staff entered the resident's room, delivered meals, and attempted to communicate in English, which the resident did not understand. There was no communication board visible in the room, and interpreter services were not used, leading to ineffective communication and potential frustration for the resident. Interviews with staff, including CNAs and the Director of Nurses, confirmed that communication boards and interpreter services were not being utilized as expected. Staff admitted to guessing or pointing to objects to communicate with the resident, which was not always successful. The Director of Nurses acknowledged the expectation for staff to follow the care plan and use the interpreter line or communication board, which was not being adhered to, resulting in a deficiency in providing adequate communication services for the resident.
Failure to Implement Contracture Management Interventions
Penalty
Summary
The facility failed to implement contracture management interventions for a resident, specifically by not ensuring the use of palm protectors. The resident, who was admitted in August 2021, has Alzheimer's disease and unspecified lack of coordination, and is dependent on staff for all activities of daily living. An occupational therapy note from December 2024 indicated that palm protectors were recommended to minimize the risk of skin breakdown, and staff were educated on their use. However, the order for palm protectors was not entered into the medical record, and the physician was not notified of the recommendation. Observations on February 11 and 12, 2025, confirmed that the resident did not have palm protectors in place. Interviews with the Assistant Director of Nursing and the Director of Rehabilitation revealed that the recommendation for palm protectors was communicated to nursing staff, but the order was not entered into the record until February 11, 2025. The Director of Nursing acknowledged that the order should have been in the record if the recommendation was made in December 2024, but noted the absence of a Functional Maintenance Plan documenting staff education.
Failure to Implement Physician-Ordered Fall Prevention Measures
Penalty
Summary
The facility failed to implement a physician-ordered intervention to mitigate injury from an accident for Resident #110. Specifically, the facility did not ensure that a fall mat was in place when Resident #110 was in bed, as ordered by the physician. The resident, who was admitted in February 2024, has diagnoses including Alzheimer's disease, a history of falling, and hemiplegia affecting the right dominant side. The resident's most recent Minimum Data Set (MDS) assessment indicated severely impaired cognition and dependence on staff for all Activities of Daily Living (ADLs). Following an unwitnessed fall from bed on August 11, 2024, a physician's order was issued for a floor mat to be placed on the window side of the bed to prevent recurrence. Despite the physician's order and the care plan intervention indicating the need for a fall mat, observations during the survey on February 11, 13, and 14, 2025, revealed that the fall mat was not in place when Resident #110 was in bed. The Treatment Administration Record for February 2025 inaccurately documented that the fall mat was in place daily on all three shifts. Interviews with Resident #110's nurse and the Assistant Director of Nursing (ADON) confirmed that the fall mat should have been in place as per the physician's order. The ADON observed the absence of the fall mat and left the unit to obtain one, indicating a lapse in adherence to the prescribed safety intervention for the resident.
Failure to Ensure Correct Catheter Size for Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for Foley catheter care for two residents. For Resident #38, the facility did not obtain the correct physician's orders for the indwelling catheter size. The resident, who was cognitively intact, had been admitted with urinary retention and required a urinary catheter. Despite the hospital discharge summary indicating a 16 French 10 mL balloon catheter, the physician's order incorrectly specified an 18 French catheter. The discrepancy was noted during an observation by the surveyor and the Director of Nursing, who confirmed that the nursing staff should have obtained the correct catheter size order. For Resident #113, the facility failed to ensure the correct size suprapubic tube (SPT) was inserted. The resident, also cognitively intact, required an indwelling catheter due to neuromuscular dysfunction of the bladder. The physician's order specified a 16 French SPT, but Nurse #8 inserted an 18 French catheter without verifying the order. This error was discovered during an observation by the surveyor and Nurse #4, who confirmed the incorrect catheter size. The Director of Nursing acknowledged that the nursing staff should have followed the physician's orders and inserted the correct size SPT.
Failure to Provide Adequate Fluid Intake as Ordered
Penalty
Summary
The facility failed to provide sufficient fluid intake as ordered by the physician for Resident #375, who was admitted with diagnoses including vascular dementia, diabetes, and chronic kidney disease. The resident's hospital discharge summary and physician's orders specified a regimen of Jevity 1.5 tube feeding and a free water bolus (FWB) of 175 mL every 4 hours to meet daily hydration needs. However, the facility's nursing staff administered the FWB only once per shift, resulting in a total fluid intake of 525 mL per day, which was significantly less than the 1050 mL required. Interviews with nursing staff revealed that the FWB was administered manually due to a lack of supplies for automatic scheduling with the tube feeding pump. The Unit Manager confirmed that the physician's order was not transcribed correctly, leading to the FWB being scheduled only once per shift. The Dietitian emphasized the importance of the FWB for maintaining adequate hydration, as fluid flushes during medication passes were not included in the resident's daily hydration needs. The Director of Nursing acknowledged that the resident should receive flushes as ordered to maintain hydration.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #38, by not changing the oxygen tubing as ordered by the physician. Resident #38, who was admitted with diagnoses including atrial fibrillation, low back pain, and chronic obstructive pulmonary disease, required continuous oxygen therapy at 3 liters per minute. The facility's policy and the physician's order required the oxygen tubing to be changed weekly, with each component labeled with the date and initials every Sunday night shift. However, observations on February 11 and 12 revealed that the oxygen tubing in use was dated December 12, 2024, indicating it had not been changed as required. Interviews with nursing staff confirmed the deficiency. Nurse #7 acknowledged that the tubing should have been changed weekly, and Nurse #6 stated that oxygen should be changed according to the physician's order. Resident #38 expressed concerns about the facility not having the correct length of oxygen tubing and mentioned being unable to change the tubing independently. The Director of Nursing also confirmed that nursing should change the oxygen in accordance with the physician's orders, highlighting a lapse in following the established protocol for oxygen administration.
Nursing Competency Deficiency in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff were competent in preparing and administering medications safely, as evidenced by the actions of a nurse who did not follow the facility's medication administration policy. Specifically, Nurse #2 was observed preparing medications for a resident without verifying the Medication Administration Record (MAR) and was preparing medications from memory. The nurse's computer screen was black, and she did not reference the MAR while preparing the medications, which is against the facility's policy that requires checking the label three times to verify the right resident, medication, dosage, time, and method of administration. The incident involved Resident #60, who was admitted with diagnoses including epilepsy, diabetes, and heart failure. During the surveyor's observation, it was found that some medications were documented as administered but were not present in the medication cup, indicating discrepancies in medication administration. Nurse #2 had signed off the medications as administered over an hour before the surveyor's observation, despite not having administered them. Interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing confirmed that Nurse #2 did not follow the proper procedures for medication administration, highlighting a deficiency in ensuring nursing competency and adherence to policy.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, leading to deficiencies in documentation. For Resident #110, who has Alzheimer's disease and a history of falls, the Treatment Administration Record (TAR) inaccurately documented the presence of a fall mat in the resident's room. Despite physician orders and care plans indicating the necessity of a fall mat to prevent falls, observations on multiple occasions revealed that no fall mat was present in the resident's room. Interviews with nursing staff confirmed the expectation for accurate documentation, yet discrepancies were noted between the TAR entries and actual observations. For Resident #13, who has end-stage renal disease and requires hemodialysis, the facility inaccurately documented blood pressure readings. Despite physician orders specifying that blood pressure should not be taken on the resident's left arm due to a dialysis fistula, records showed that staff documented using the left arm for blood pressure measurements 17 times. Interviews with the resident and nursing staff confirmed that the left arm was never used for such measurements, and the documentation was acknowledged as erroneous. The Director of Nursing emphasized the expectation for accurate documentation, highlighting the discrepancy between recorded and actual practices.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide the required written notice to the State Agency regarding a change in the Administrator. The Health Care Facility Reporting System (HCFRS) did not contain documentation to support that the facility had informed the State Agency of the new Administrator, who started on November 1, 2024. Interviews conducted on February 12, 2025, revealed that the Director of Nursing believed the State Agency had been notified, while the Administrator was unaware that the notification had not been made. This oversight resulted in a deficiency related to the facility's obligation to disclose changes in administrative personnel to the State Agency.
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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