Maplewood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amesbury, Massachusetts.
- Location
- 6 Morrill Place, Amesbury, Massachusetts 01913
- CMS Provider Number
- 225229
- Inspections on file
- 28
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maplewood Center during CMS and state inspections, most recent first.
Several residents with pressure ulcers did not receive wound care as recommended by the wound consultant, with delays or omissions in updating treatment orders, incomplete documentation of wound care administration, and failure to implement interventions such as dressing changes, offloading, and nutritional supplements. Staff interviews revealed confusion about responsibilities for entering and following wound care orders, and observations confirmed that some residents were without necessary treatments or offloading measures.
The facility did not maintain adequate LPN/RN and CNA staffing as outlined in its own assessment, with multiple shifts—especially on weekends—falling below required levels. Residents reported long waits for assistance and missed showers, while staff described frequent short-staffing and inability to complete care tasks. Leadership acknowledged ongoing staffing challenges, and PBJ data confirmed low staffing ratings and days without RN coverage.
Nursing staff were not provided with or documented as having completed required training and competency assessments in key clinical areas, including wound care, ADLs, infection control, and medication administration. This led to inadequate care for multiple residents, including the worsening of a pressure wound for a resident due to failure to follow wound consultant recommendations. Facility leadership confirmed that expected training and competency checks were not performed or documented.
The facility did not ensure an RN was onsite for at least eight consecutive hours each day as required, with staffing records and interviews confirming multiple days without RN coverage and no staffing waivers in place. The DON and Administrator acknowledged the absence of consistent RN scheduling and ongoing staffing challenges.
Annual performance reviews for all eligible CNAs were not completed or documented, as confirmed by both the Human Resource Director and the DON. The DON stated that no reviews had been conducted since assuming the position, and the HR Director indicated the process was previously managed by the former DON.
Facility administration failed to ensure staff received proper orientation, education, and competency assessments, resulting in inadequate wound care for a resident and lack of clinical competencies among staff. The facility also did not maintain an effective Infection Prevention and Control Program, lacked infection tracking and reporting, and did not have a qualified Infection Preventionist. Staffing levels were below required minimums, and key management positions remained vacant, with no plan developed to address these issues.
The facility did not complete or document a comprehensive assessment to determine necessary staffing, training, and competencies for resident care, and failed to implement an effective infection control surveillance plan. Leadership interviews confirmed that required staff training and competencies were not completed or on file, and that there was no qualified infection preventionist or staff educator in place.
Surveyors found that two residents with wounds and medical devices were not provided with Enhanced Barrier Precautions or proper PPE during care, and staff failed to perform hand hygiene between glove changes. The facility lacked an active Infection Preventionist, had no documented infection surveillance or tracking, and did not maintain a water management program for Legionella, with leadership confirming the absence of required infection control documentation and oversight.
The facility did not implement or document its Antibiotic Stewardship Program as required by policy, failing to track, follow up, or review antibiotic use for residents over an extended period. Interviews with the DON and Administrator confirmed the absence of an Infection Preventionist and a lack of monitoring or documentation related to antibiotic stewardship.
The facility did not designate a qualified infection preventionist (IP) to oversee the infection prevention and control program, as required by policy. Documentation for the IP role was incomplete, and leadership confirmed that no staff member with the necessary infection control certification was assigned to this responsibility. The absence of a designated IP was acknowledged by the DON, Administrator, and President of Clinical Operations.
Surveyors found that MDS assessments were inaccurately coded for three residents, including errors in documenting diagnoses such as anxiety, depression, and pressure injuries, as well as improper coding regarding the clinical contraindication for gradual dose reduction of antipsychotic medication. These inaccuracies were confirmed through record review and staff interviews.
Multiple residents with cognitive impairment and high risk for pressure ulcers did not receive weekly skin assessments as ordered, and in some cases, injuries were treated without physician orders or proper documentation. Nursing staff and the DON acknowledged ongoing issues with completing and documenting required skin checks, and there was a lack of oversight in ensuring adherence to physician orders.
Surveyors found the medication storage room on a nursing unit unlocked and unattended on two occasions, with residents present in the area. Facility policy requires all drugs and biologicals to be stored in locked compartments, accessible only to authorized nursing staff. Interviews with a nurse and the DON confirmed the room should always be locked, but it was left unsecured, allowing unauthorized access.
The facility did not develop or implement effective QAPI action plans to address deficiencies in pressure ulcer management, infection control surveillance, adequate nursing staffing, and annual wound care competencies. QAPI meeting records lacked specific action plans, and key interdisciplinary team members were absent from meetings. Leadership interviews confirmed that systemic issues, such as nurses not following wound consultant recommendations and incomplete infection control surveillance, were not identified or addressed through the QAPI process, resulting in uncorrected quality deficiencies.
The facility did not offer the COVID-19 vaccine to three out of five new employees during orientation and failed to track staff vaccination status, with interviews revealing confusion among HR, DON, and administration regarding responsibility for vaccination tracking and offering, compounded by the absence of an Infection Preventionist.
The facility did not maintain documentation showing that two CNAs completed the required 12 hours of annual continuing education. When surveyors requested proof of training, neither the DON nor the HR Director could provide the necessary records, with the HR Director stating she was unaware of the specific requirements.
A resident with multiple chronic conditions repeatedly refused prescribed furosemide, but the physician was not notified as required by facility policy. Staff interviews confirmed that the refusals were not communicated to the physician, and the resident was not educated about the potential effects of refusing the medication.
A resident admitted with a history of opioid use disorder, depression, anxiety, and prior suicide attempts did not have a baseline care plan developed within 48 hours that addressed their substance use and suicide history. Despite available documentation and staff awareness of the resident's background, the required person-centered interventions were not included in the initial care plan.
A resident with a history of spinal fusion, malnutrition, and anemia developed pressure ulcers that were documented by a wound consultant over several months. Despite ongoing pressure injuries, the care plan did not include individualized interventions or address the actual skin breakdown until the issue was identified by surveyors, as confirmed by the DON.
A resident with diabetes and congestive heart failure, who was cognitively intact, did not receive scheduled showers for approximately 12 weeks. The resident reported not refusing showers and expressed a desire to have them, but showers were not offered consistently, reportedly due to staffing issues. Staff interviews and documentation reviews confirmed a lack of evidence that showers were provided or refused, and the only record available was the shower schedule on assignment sheets.
A resident with COPD and CHF was observed receiving oxygen therapy without a physician's order or a care plan addressing oxygen use. Staff and the DON confirmed that both were required but missing.
Two residents, one with schizophrenia and another with Alzheimer's disease, did not receive required face-to-face physician visits following admission. Instead, they were primarily seen by a nurse practitioner and for behavioral health follow-ups, while the attending physician's visits did not meet the mandated schedule. Both the DON and physician were unaware of the 30-day visit requirement for the first 90 days after admission, resulting in noncompliance.
A resident with dementia, hemiplegia, anxiety, and depression did not receive ongoing psychotherapy or timely care planning for behavioral health needs. Despite an initial assessment recommending regular therapy, no further psychotherapy was provided and a care plan addressing depression and anxiety was not developed until months after admission.
A resident with impaired kidney function and recent falls continued to receive a higher dose of gabapentin for several months, despite the pharmacist’s recommendations and agreement from the NP and physician to reduce the dose. The facility did not implement the medication changes as directed, and staff interviews confirmed that pharmacy recommendations were not promptly addressed.
The facility did not provide SNF ABN notices to two residents who stayed after skilled services ended, as required by policy. Both the DON and Administrator confirmed that the necessary notifications about potential financial liability for continued services were not issued.
The facility did not consistently post daily nurse staffing information in a location accessible to residents and visitors. Observations showed that the required staffing data was either missing or hidden behind a blank sheet near the receptionist desk, and staff confirmed that the information was instead posted in an employee-only area.
Residents repeatedly reported receiving cold food and inconsistent meal temperatures. Observations showed staff struggled to keep plate covers on trays, resulting in food being left uncovered during delivery. Temperature checks confirmed that both hot and cold items were not at appropriate serving temperatures, and the Food Service Director acknowledged insufficient plate covers contributed to the problem.
Surveyors found that food items in two nourishment kitchenettes were not stored, labeled, or discarded according to facility policy, with multiple expired and unlabeled items, dirty surfaces, and improper storage of personal staff items. Despite clear policies and staff responsibilities, observations revealed ongoing non-compliance with food safety and sanitation standards.
A resident with multiple chronic conditions experienced a change in condition and was transferred to the hospital after calling EMS. The nurse on duty did not assess the resident, communicate with EMS, or document the transfer and return in the medical record, resulting in incomplete and inaccurate documentation as required by facility policy.
The facility did not conduct Massachusetts Nurse Aide Registry background checks for three employees before hiring, as required by its policy to prevent abuse, neglect, and exploitation. The HR Director, responsible for these checks, was not trained in conducting them, leading to a lack of documentation for the required checks.
A resident with Hodgkin's lymphoma and shoulder pain reported being roughly handled by a CNA, leading to increased pain and feelings of violation. The facility failed to investigate or report the incidents as abuse allegations, managing them as customer service issues instead. The Administrator was not informed, and no documentation or witness statements were collected.
A resident with intact cognition and multiple diagnoses reported being handled roughly by a CNA, but the facility failed to implement its abuse policy. The DON and ADON did not notify the Administrator or suspend the staff member involved, and the allegations were not reported to the state agency or law enforcement. The concerns were managed as customer service issues, and necessary documentation and investigation were not completed.
A resident with Hodgkin's lymphoma and shoulder pain reported two incidents of alleged abuse by a CNA, including rough bathing and aggressive handling, causing shoulder pain. Despite the facility's policy to report abuse within two hours, these incidents were not reported to authorities, and were instead managed as customer service issues.
A resident with Hodgkin's lymphoma and shoulder pain reported two incidents of rough handling and bathing by a CNA, which were not properly investigated by the facility. Despite the resident's intact cognition and reports to the DON and family, the facility treated the allegations as customer service issues rather than abuse. Interviews with staff confirmed no formal investigation was conducted, violating the facility's policy and resulting in a deficiency.
The facility failed to conduct the required controlled substance count at shift change, as per policy. A night shift nurse left without performing the count with the incoming day shift nurse, resulting in incomplete documentation in the controlled substance logbooks. The Director of Nursing confirmed the requirement for both nurses to conduct and document the count during shift changes.
The facility failed to provide meals that were palatable, attractive, and served at appropriate temperatures. Residents reported dissatisfaction with the food, describing it as unappetizing and often served at incorrect temperatures. Observations confirmed these issues, with meals being either too cold or too warm, lacking condiments, and described as bland and mushy. The food service manager acknowledged the expectation for meals to be palatable and served at correct temperatures, but the facility did not meet these standards.
The facility failed to implement its QAPI plan during a leadership transition, resulting in deficiencies in RN staffing and quality of care. The facility did not identify or develop a plan for RN services and allowed the DON to work as a charge nurse. The facility's staffing report indicated a one-star rating due to insufficient RN hours, which was not addressed in QAPI meetings or through a PIP.
The facility failed to maintain an effective infection prevention and control program by not tracking and trending infections for several months and lacking a policy for this process. Additionally, the facility did not implement a water management program to minimize the risk of Legionella and other pathogens, as confirmed by the Maintenance Director.
The facility did not implement its Antibiotic Stewardship Program as required by its policy. The policy mandated the collection and documentation of antibiotic usage and outcome data to guide improvement decisions. However, the DON, responsible for the program's implementation and monitoring, acknowledged not completing the monitoring, tracking, and trending of antibiotic use.
A facility failed to maintain professional nursing standards, resulting in missed medication doses for three residents and non-compliance with a physician's order for a health care proxy re-evaluation for another resident. Medications for conditions like atrial fibrillation, hypertension, and epilepsy were not administered as ordered, with no documentation provided. Additionally, a required cognitive assessment was not completed, impacting the decision on a health care proxy.
The facility failed to maintain adequate staffing levels, impacting resident care on two units. The Facility Assessment Tool lacked a completed staffing plan, and the Payroll-Based Journal Staffing Data Report showed low weekend staffing. Residents reported long wait times for assistance, especially during evening shifts and weekends. Staff confirmed frequent shortages of CNAs, affecting care and medication administration. The facility's scheduler noted difficulties in covering shifts, with working schedules showing multiple instances of reduced staffing.
The facility failed to maintain the required RN staffing levels, with the DON covering shifts due to shortages. The facility's staffing report indicated a one-star rating, and the Administrator was unaware of the issue. The DON worked various shifts, impacting her ability to fulfill her primary duties.
The facility failed to address pharmacist recommendations timely for three residents. A resident was given an antipsychotic without a supporting diagnosis, and the medication was not discontinued as recommended. Another resident's serum level for Divalproex was not monitored promptly. A third resident's Quetiapine dosage was not tapered as advised. The DON and physician acknowledged that recommendations should be implemented within 24 hours, but this was not done.
The facility did not address resident grievances raised during Resident Council Meetings, as required by their policy. Issues such as missing condiments, untimely call light responses, and insufficient staffing were not documented or resolved. The Activity Director communicated concerns verbally but did not use grievance forms, and a meeting was missed due to a broken elevator, further delaying resolution.
The facility failed to accurately complete MDS assessments for two residents, leading to documentation deficiencies. One resident experienced significant weight loss not reflected in the MDS, while another had dental issues inaccurately reported. The MDS Nurse acknowledged these oversights, and the Assistant DON expected accurate documentation.
A resident with a history of suicidal ideations and alcohol abuse did not have personalized care plans developed by the facility, despite policy requirements. The resident, diagnosed with depression and moderately impaired cognition, had documented severe mood disorder symptoms and a past hospitalization for suicidal thoughts. Interviews confirmed that care plans should have been created to address these issues.
A resident with hearing loss and dementia did not receive necessary audiology services despite family concerns and doctor's recommendations. The resident, who had moderate difficulty hearing, was unable to pass a whisper test with hearing aids. Although a doctor's note recommended an audiologist evaluation, no appointment was made, and the facility lacked a policy for audiology consults.
A resident with chronic conditions and moderate cognitive impairment was admitted to the facility and identified as high risk for pressure ulcers. Despite this, the facility failed to conduct weekly skin assessments as required by their policy, missing five weeks of checks. Interviews revealed that the necessary physician's order for these assessments was not entered upon admission.
A facility failed to ensure proper labeling of a G-tube feeding bag and water flush bag for a resident with dysphagia and legal blindness. The bags lacked necessary information such as the resident's name, contents, and staff initials, contrary to facility policy. Observations on two occasions confirmed the deficiency, and a nurse acknowledged the labeling requirements.
The facility failed to re-evaluate psychotropic medications for two residents after 14 days, as required by CMS guidelines. One resident with dementia was given Seroquel PRN beyond the 14-day limit without a doctor's review, despite a pharmacist's recommendation to discontinue. Another resident with dementia and delusional disorders had a Quetiapine PRN order for 100 days, which was not adjusted despite multiple pharmacist requests. The physician agreed with the recommendations, but they were not implemented promptly, leading to continued medication administration without proper evaluation.
Failure to Implement and Document Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Multiple residents, including those with severe cognitive impairment and total dependence on staff for activities of daily living, did not have wound consultant recommendations implemented in a timely manner, or at all. For example, one resident with a stage 4 left heel pressure ulcer did not receive the updated treatment recommended by the wound consultant for nearly a month after the wound was debrided and restaged. The treatment administration records continued to reflect the previous regimen, and the new orders were not entered or implemented until much later, despite clear communication from the wound consultant and expectations from the medical director and nurse practitioner that recommendations be followed. In several cases, documentation was incomplete or missing, with treatment administration records left blank on multiple days without corresponding progress notes or evidence that treatments were refused. For one resident, eight wound treatments were not documented as provided in a single month, and there was no supporting documentation to indicate whether the treatments were completed or refused. Interviews with nursing staff and the DON confirmed that blank records meant there was no evidence the treatments were done, and that staff were unclear about their responsibilities for entering and implementing wound care orders. Other residents with pressure injuries, including those with new or worsening wounds, did not have wound consultant recommendations such as specific dressing changes, offloading, repositioning, or nutritional supplements implemented or documented in the medical record. In some cases, recommendations for supplements like zinc were delayed for months, and care plans were not updated to reflect actual skin breakdown or new interventions. Observations confirmed that residents were without ordered treatments or offloading measures, and staff were unaware of current wound care needs or orders. The failure to implement and document wound care recommendations was consistent across multiple residents and over extended periods.
Failure to Maintain Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of residents, as required by their own facility assessment and federal regulations. The Facility Assessment Tool, reviewed in May 2024, established minimum staffing levels for LPNs/RNs and CNAs for each shift, but multiple reviews of actual daily schedules revealed that the facility consistently scheduled fewer staff than required, particularly on weekends. Payroll-Based Journal (PBJ) data for Quarter 1 of 2025 triggered a one-star staffing rating, excessively low weekend staffing, and multiple days with no RN hours. Specific dates were identified where both nurse and CNA staffing fell below the facility's stated minimums, with some shifts missing as many as half the required staff. Residents reported significant delays in receiving care, including long waits for assistance with call lights, showers, and bathroom needs. During interviews, several residents stated they had not received showers for weeks, with one resident reporting a 12-week gap. At a resident group meeting, the majority of attendees indicated they often waited over 25 minutes for assistance. Staff interviews corroborated these concerns, with CNAs and nurses describing frequent short-staffing, inability to complete showers or care tasks, and the need for staff to work double shifts or stay late due to lack of coverage. Staff also reported that posted schedules did not accurately reflect the number of staff actually present in the building. Facility leadership, including the scheduler, DON, and administrator, acknowledged ongoing staffing issues and efforts to recruit or use agency staff. The medical director confirmed the facility was understaffed and overworked, noting frequent turnover in nursing leadership. The deficiency was further supported by direct observations from surveyors and multiple staff and resident interviews, all indicating that the facility did not maintain adequate staffing to meet residents' needs as outlined in their own assessment and regulatory requirements.
Failure to Ensure Nursing Staff Competency and Required Training
Penalty
Summary
The facility failed to ensure that nursing staff, including both licensed nurses and nurse aides, were properly trained and demonstrated the necessary competencies to provide care as outlined in the Facility Assessment. Specifically, the facility did not ensure that licensed nursing staff were trained and competent in identifying, assessing, evaluating, intervening, and responding to changes in wound conditions, nor did they implement treatment recommendations for several residents. For one resident, this failure resulted in the deterioration of a pressure wound from stage 2 to unstageable over a three-month period due to the lack of implementation of wound consultant recommendations. A review of seven clinical nursing staff personnel files revealed that the facility did not conduct or document required training and competency evaluations upon hire or annually, as specified in the Facility Assessment. The missing competencies included essential areas such as activities of daily living (ADLs), fall prevention, change in condition, skin integrity, infection control, dementia care, and medication administration. There was no evidence that staff had completed or demonstrated competency in these areas, nor that such training was provided as required. Interviews with facility leadership, including the DON, Administrator, Medical Director, and President of Clinical Operations, confirmed that the expected training and competency checks had not been completed. The DON acknowledged that no training or competency assessments had been conducted with clinical staff, and the Administrator noted the absence of key staff responsible for education and training, resulting in uncertainty about the current training system. Leadership agreed that the required education and competencies were not maintained as per facility policy and regulatory requirements.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulation. Review of Payroll-Based Journal (PBJ) Staffing Data and facility nursing schedules revealed that on multiple specific dates, there was no evidence that an RN was onsite for the required hours. The facility did not have any staffing waivers in place during this period. The absence of RN coverage was confirmed through the lack of supporting timecards or payroll documentation for the identified dates. Interviews with the Director of Nursing (DON) and the Administrator confirmed ongoing staffing issues and the lack of a consistently scheduled RN. The DON stated she was not employed during the period in question but acknowledged that RN coverage should have been provided according to regulations. The Administrator also confirmed that there were no staffing waivers and that an RN should be present daily for at least eight hours.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all three eligible Certified Nurse Aides (CNAs) whose records were reviewed. During the survey, the surveyor was unable to locate documentation of annual performance reviews in the employee records for these CNAs. The Human Resource Director confirmed that the reviews had not been completed and stated that she does not manage this process, as it was previously handled by the former Director of Nursing. The current Director of Nursing acknowledged that annual reviews are required and documented in employee records, but admitted that no performance reviews had been conducted since she began her role in April 2025.
Administrative Oversight Failure Leads to Deficiencies in Staff Training, Infection Control, and Staffing
Penalty
Summary
Facility administration failed to provide appropriate oversight to ensure staff orientation, education, and training, resulting in staff lacking clinical competencies necessary for safe and effective resident care. Specifically, licensed staff did not have documented competencies related to wound management and communication with consulting providers, which led to the deterioration of a wound for one resident. The Director of Nursing confirmed that no training or competencies had been completed with clinical staff, and new hires were not properly oriented or assessed for competency. The facility did not establish or maintain an effective Infection Prevention and Control Program (IPCP), including the absence of Enhanced Barrier Precautions and proper hand hygiene during wound care. There was no system in place for tracking, monitoring, or reporting infections and communicable diseases, and the facility failed to document infection data for multiple consecutive months. Additionally, the facility did not develop or implement an Antibiotic Stewardship Program and lacked a qualified Infection Preventionist to oversee the IPCP. Staffing levels were below the facility's determined minimum requirements for licensed nurses and CNAs, and the facility did not provide the services of a registered nurse for at least eight consecutive hours a day, seven days a week, without an approved waiver. Key management roles, including Assistant Director of Nursing, Unit Managers, Infection Preventionist, and Staff Development Coordinator, were vacant for an extended period, and the administrative team did not develop a plan to address these deficiencies or ensure the facility could safely meet residents' needs.
Failure to Assess and Provide Necessary Resources and Competencies for Resident Care
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately address sufficient staffing, educational resources, or a competency-based approach for staff training and evaluation. Specifically, the facility did not identify or document the competencies required upon orientation or annually, nor did it ensure that staff had the knowledge and skills necessary to maintain or improve residents' physical, functional, mental, and psychosocial well-being in accordance with professional standards of practice. The facility also failed to implement an effective infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Interviews with facility leadership revealed that required staff training and clinical competencies had not been completed or documented, and that the DON, who was covering the roles of infection preventionist and educator, lacked the necessary specialized training in infection prevention and control. The facility did not have a designated or qualified infection preventionist, nor did it employ an Assistant Director or Staff Educator to manage staff competencies. Staffing shortages were also noted, and the Administrator was unaware of the specific competencies required for clinical staff, further contributing to the deficiency.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For one resident with a right hip surgical incision and a PICC line, there was no Enhanced Barrier Precautions (EBP) signage or Personal Protective Equipment (PPE) cart available prior to room entry on several occasions. Additionally, a nurse was observed hanging an IV line while wearing only gloves and no other PPE. The Director of Nurses confirmed that EBP signage and PPE should have been present due to the resident's wounds and medical devices, but these measures were not in place. Another resident with severe cognitive impairment and multiple unhealed pressure ulcers was not provided with EBP during wound care. During a wound dressing observation, nurses failed to don gowns and did not perform hand hygiene between glove changes, despite handling open wounds. The nurse involved acknowledged that residents with wounds should be on EBP and that she should have worn a gown and performed hand hygiene, but these protocols were not followed. The Director of Nurses, acting as the Infection Preventionist, also stated that EBP should have been implemented for residents with wounds and that staff should wear gowns and gloves during wound care. The facility also lacked a documented infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. The Director of Nurses admitted there was no active Infection Preventionist, no line listings, and no data available regarding infection rates or surveillance. Furthermore, the facility did not have a documented water management program to address the risk of Legionella and other waterborne pathogens, and key staff were unaware of the required assessments and control measures. These failures were confirmed through interviews with facility leadership, who acknowledged the absence of required infection control documentation and oversight.
Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program as outlined in its policy, which requires monitoring and documentation of antibiotic use among residents. During the survey, there was no evidence of tracking, follow-up, or review with physicians or nurse practitioners after antibiotics were prescribed for any of the seven active antibiotic orders. Additionally, there was no documented information related to antibiotic stewardship for a period spanning from August 2024 through June 2025. The facility's policy also mandates staff orientation, training, and education on the importance of antibiotic stewardship and its impact on residents and the community, but there was no documentation to show these activities were occurring. Interviews with the DON and the Administrator confirmed that antibiotics should be tracked, documented, and reported, but revealed that the facility did not have an active Infection Preventionist in place. The DON acknowledged that while she is informed during morning meetings if someone is on antibiotics, she has not been tracking or monitoring specific data related to antibiotic stewardship and does not maintain line listings. The Administrator also confirmed the absence of an Infection Preventionist and stated that a staff member had been assisting with the program but was no longer available.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) responsible for the infection prevention and control program (IPCP), as required by facility policy and federal regulations. Review of the facility's Infection Control Policy and Procedure indicated the need for one or more individuals to be designated as the IP, responsible for developing, implementing, and overseeing the IPCP, including surveillance and staff training. However, the facility's documentation for the designation of an IP was left blank, and the facility assessment only referenced a plan for one full-time IP/ADON without evidence of actual assignment or qualification. Interviews with facility leadership confirmed that there was no qualified IP in place. The DON, who started in the role recently, acknowledged lacking the required infection control certification and stated that the facility did not have an approved IP. The Administrator and the President of Clinical Operations both confirmed the absence of an IP, noting that a staff member who previously assisted with the role was no longer employed. No information was provided regarding any residents directly affected at the time of the deficiency.
Inaccurate MDS Coding for Diagnoses and Medication Management
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including dementia, encephalopathy, and bipolar disorder, the MDS was inaccurately coded to indicate that a gradual dose reduction (GDR) of antipsychotic medication was clinically contraindicated, based on documentation from a psychiatric nurse practitioner. However, review of the nurse practitioner's notes did not support that a GDR was clinically contraindicated, and the MDS nurse acknowledged that the notes used were not appropriate for coding the MDS. Additionally, another resident with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder had multiple MDS assessments that failed to include the diagnoses of anxiety and depression, as the MDS nurse was unaware of these diagnoses. A third resident with a history of stroke and dementia had an MDS assessment that inaccurately coded the presence and development of pressure injuries, with the MDS nurse confirming the inaccuracy. These findings were based on record reviews and staff interviews.
Failure to Complete and Document Required Skin Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality, specifically regarding the implementation and documentation of skin assessments and adherence to physician orders for multiple residents. Several residents with significant cognitive impairments and high risk for pressure ulcers did not receive weekly skin assessments as ordered by their physicians. For example, one resident with severe cognitive impairment and high risk for pressure ulcers had only 8 weekly skin assessments documented over a 27-week period, despite a standing physician order for weekly checks. Similar deficiencies were found for other residents, where weekly skin checks were either missed or not documented in the electronic medical record, and there was no evidence of resident refusal or alternative documentation. In another instance, a resident was observed with a dressing on the lower right leg, but there was no corresponding physician order or documentation of the injury or treatment in the medical record. Nursing staff were unaware of the origin of the injury or the presence of a treatment order, and the DON confirmed that the expected protocol of assessment, physician notification, and obtaining treatment orders was not followed. Additionally, for a resident requiring a wrist splint, there was a physician order for pre- and post-use skin checks, but the clinical record did not contain any documentation of these assessments, and the resident reported that nursing staff did not check the skin under the splint. Interviews with nursing staff and the DON revealed an ongoing issue with the completion and documentation of required skin assessments. Staff acknowledged that physician orders for weekly skin checks were not consistently followed, and there was a lack of oversight due to recent changes in nursing leadership. The DON was aware of the deficiencies and confirmed that the facility had been experiencing problems with ensuring that nursing staff completed and documented skin checks as ordered.
Medication Storage Room Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that the medication storage room on the first floor Unit 1 was found unlocked and unattended on two separate occasions. During both observations, the surveyor was able to open the door and access the medication storage room without any staff present in or around the area, while residents were seen walking around the unit. The facility's policy requires all drugs and biologicals to be stored in locked compartments, and only authorized personnel are permitted access to the medication room. Interviews with nursing staff and the Director of Nursing confirmed that the medication storage room is required to remain locked at all times, and only nursing staff with keys should have access. Despite this policy, the medication storage room was left unsecured, allowing unauthorized access to medications and biologicals.
Failure to Implement Effective QAPI Action Plans for Wound Care, Infection Control, and Staffing
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP) to address several critical areas, including pressure ulcer management, infection control surveillance, adequate nursing staffing, and annual wound care competencies. Record review revealed that quarterly QAPI meetings were held, but the meeting summaries did not include specific action plans for implementing wound consultant recommendations, infection control surveillance (including antibiotic stewardship and line listing), ensuring sufficient and qualified nursing staff, or verifying that nursing staff had completed annual wound care competencies. Sign-in sheets for QAPI meetings also showed that key interdisciplinary team members, such as the Assistant Director of Nurses, Staff Development Coordinator, and Infection Preventionist, were not present or did not sign in for multiple meetings. Interviews with facility leadership confirmed these deficiencies. The Director of Nurses (DON), who started in April 2025, acknowledged awareness of wound care concerns and identified a culture where nurses did not add wound consultant recommendations to physician orders, which led to the deterioration of a wound for a resident. The DON stated that no PIPs addressing wound recommendations, infection control surveillance, staffing, or annual wound competencies had been initiated prior to her start date. She indicated that systemic issues were expected to be identified by the interdisciplinary team and brought to QAPI for action planning, but this process was not followed. The Administrator, who began in August 2024, reported managing three quarterly QAPI meetings but did not initiate PIPs for the specific issues identified, including wound care, staffing, infection control surveillance, and annual wound competencies. He attributed this to a lack of awareness of these specific concerns and noted that the DON did not inform him of the issues. The Administrator also confirmed that there was a period without a permanent Infection Preventionist, Staff Development Coordinator, or Assistant Director of Nurses, and that he was unaware of the absence of an infection control surveillance plan and incomplete staff wound care competencies. These failures resulted in the facility not addressing or correcting systemic quality deficiencies.
Failure to Offer and Track COVID-19 Vaccination for New Staff
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to three out of a sample of five employees, specifically by not providing the vaccine during new hire orientation. Record review showed that three of the five employee health records indicated the employees had not been vaccinated for COVID-19. The facility assessment required following CDC and DPH guidelines for infection prevention and control, including COVID-19 response. Interviews revealed a lack of clarity and responsibility regarding the tracking and offering of COVID-19 vaccinations to staff. The Human Resources Director stated she requests vaccination cards and notifies the DON if a staff member does not have one, but does not track vaccinations or know if the vaccine was offered during orientation. The DON indicated that immunization records are received by Human Resources but does not track them and was unsure who is responsible for tracking vaccinations. The Administrator expected vaccinations to be tracked and offered to all staff but was also unsure who was responsible, noting the absence of an Infection Preventionist. The President of Clinical Operations confirmed the facility had been without an Infection Preventionist and that a staff member previously assisting in the role was no longer present.
Failure to Maintain Required CNA Training Records
Penalty
Summary
The facility failed to maintain records demonstrating that Certified Nurse Aides (CNAs) completed at least 12 hours of mandatory continuing competency training per year, as required. During the survey, the survey team requested proof of annual CNA training for five employees, but education records for two CNAs did not indicate that the required training had been completed or documented. The Director of Nursing (DON) confirmed that she could not provide additional education records for these CNAs and stated that such records should be kept in employee folders. The Human Resource Director (HR) reported that she manages onboarding and policy training during orientation, while the DON is responsible for clinical training, but the HR Director was unaware of the specific training requirements and could not provide further documentation for the two CNAs.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusals of an ordered medication, specifically furosemide, which is used to remove fluid. According to the facility's policies, staff are required to notify the attending physician when there is a need to alter treatment significantly, such as when a medication is refused. Record review showed that the resident, who was cognitively intact and had diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Congestive Heart Failure, refused furosemide on seven occasions over a ten-day period. There was no documentation in the clinical record indicating that the physician was informed of these refusals. Interviews with nursing staff, including a nurse, the Director of Nursing, and the Nurse Practitioner, confirmed that the physician was not notified of the medication refusals. Staff acknowledged that the physician should have been informed and that the resident should have been educated about the potential adverse effects of refusing the medication. The lack of notification was identified through both record review and staff interviews.
Failure to Develop Timely Baseline Care Plan Addressing Substance Use and Suicide History
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Specifically, the baseline care plan did not address the resident's history of substance use (heroin) and suicide attempts, despite this information being available in the hospital discharge paperwork and psychiatric consults. The resident was admitted with diagnoses including psychoactive substance induced disorder, depression, and anxiety, and had a documented history of opioid use disorder (on suboxone maintenance), prior inpatient psychiatric hospitalization, and previous suicide attempts or statements. Interviews with facility staff revealed that the social worker, who was responsible for completing the social service section of the baseline care plan, acknowledged that the resident's suicide attempt history and heroin use history should have been included. The Director of Nurses and MDS coordinator both confirmed that baseline care plans are expected to be completed within 48 hours of admission and should be personalized based on the resident's history. The omission was identified during a review of the resident's records and confirmed through staff interviews.
Failure to Develop Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who developed pressure ulcers after admission. The resident, admitted with a history of spinal fusion, protein calorie malnutrition, and iron deficiency anemia, was found to have developed two stage 2 pressure ulcers on the lower back, as documented by a wound consultant. Subsequent wound consultant notes indicated ongoing pressure injuries over several months. Despite these findings, the resident's care plan did not include individualized interventions or a plan of care addressing the actual skin breakdown and development of pressure ulcers. This omission was confirmed during an interview with the Director of Nurses, who acknowledged that a care plan for the pressure injuries was not in place until after the issue was identified by surveyors.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
A resident with diagnoses including diabetes and congestive heart failure, who was cognitively intact, did not receive scheduled showers for approximately 12 weeks. The resident reported not refusing showers and expressed a desire to have them, stating that showers were not being offered and that it depended on staffing levels. Interviews with staff confirmed that showers were scheduled twice weekly and that refusals were to be documented by CNAs and communicated to nurses, who would then document in the electronic medical record. However, review of CNA documentation, nurses' progress notes, and shower checklists over a two-month period showed no evidence that the resident received or refused showers during this time. Further interviews with nursing staff and the Director of Nursing revealed a lack of documentation regarding the resident's showers or refusals, and the only information available was the shower schedule on assignment sheets. The facility failed to provide necessary care and services related to showers, as required, and did not maintain adequate records to demonstrate that the resident was offered or received showers according to their care plan.
Failure to Obtain Physician's Order and Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic obstructive pulmonary disease and congestive heart failure by not obtaining a physician's order for the administration of oxygen. The resident was observed on two occasions receiving oxygen via nasal cannula at 4 liters per minute, but a review of the medical record revealed no physician's order authorizing this treatment. Additionally, the resident's care plan did not address the use of oxygen. Interviews with nursing staff and the Director of Nursing confirmed that both a physician's order and a care plan for oxygen use were required but were not present.
Failure to Complete Required Physician Visits Upon Admission
Penalty
Summary
The facility failed to ensure that physician visits were completed as required upon admission for two residents. According to facility policy, the attending physician is responsible for participating in resident assessments and care planning, including timely face-to-face visits. For one resident with schizophrenia, records showed that after admission, the resident was seen by a nurse practitioner and had behavioral health follow-ups, but the attending physician only saw the resident once within the required timeframe. Similarly, another resident with Alzheimer's disease was seen by a nurse practitioner and had behavioral health visits, but the attending physician's visits did not meet the required schedule following admission. Interviews with the Director of Nursing (DON) and the attending physician revealed a lack of awareness regarding the regulatory requirement for physician visits every 30 days for the first 90 days after admission. Both the DON and the physician believed that visits every 60 days were sufficient, and the DON was unsure about the alternating frequency of visits. This misunderstanding led to the failure to complete physician visits as mandated for newly admitted residents.
Failure to Provide Behavioral Health Services and Timely Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident diagnosed with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder. Upon admission, the resident was moderately cognitively impaired and expressed interest in counseling or therapy services, but reported not being offered any such services during their stay. Review of the clinical record showed that a care plan addressing depression and anxiety was not initiated until approximately nine months after admission. Prior to this, there was no evidence of a care plan targeting these behavioral health needs. Additionally, documentation indicated that after an initial behavioral health assessment and recommendation for psychotherapy 1-2 times per month, there was no record of the resident receiving any psychotherapy services following the initial visit. Interviews with facility staff, including the Social Worker and DON, confirmed uncertainty regarding the implementation of a care plan for depression and anxiety prior to the late initiation and acknowledged that the resident had not received the recommended psychotherapy services, with no explanation provided by the behavioral health agency.
Failure to Implement Agreed Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician or nurse practitioner’s response for one resident. The consulting pharmacist made recommendations on two occasions to adjust the resident’s gabapentin dosage due to impaired kidney function and recent falls, with the physician and nurse practitioner both agreeing to the recommendations. However, the medical record did not show that these recommendations were acted upon, and the resident continued to receive the higher dose of gabapentin for several months following the recommendations. Interviews with the DON, nurse practitioner, and medical director confirmed that pharmacy recommendations, once agreed upon, should have been implemented by nursing staff. The DON acknowledged that pharmacy recommendations were behind in being addressed, and the nurse practitioner confirmed that the resident’s medication order had not been changed as recommended. The medical director also stated that agreed-upon pharmacy recommendations should result in a new order being placed in the medical record.
Failure to Issue SNF ABN Notices After Skilled Services Ended
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices of Non-Coverage (SNF ABN) to two residents who remained in the facility after their skilled services ended. Record review showed that, although the facility's policy requires informing beneficiaries about potential non-coverage and their financial liability for continued services, there was no documentation that SNF ABN notices were provided to these residents after the end of their skilled services. Interviews with the Director of Nurses and the Administrator confirmed that the required SNF ABN notices were not issued for the two residents, despite the expectation that such notices should be given to inform residents of their potential financial responsibility for certain services.
Failure to Post Daily Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to consistently post daily nurse staffing information in a location accessible and visible to residents and visitors, as required. During multiple observations, the surveyor noted that the designated document holder near the receptionist desk contained only a blank sheet of paper, with no visible staffing data. The receptionist confirmed that staffing information was posted near the employee time clock, an area not accessible to residents or families, and that no staffing data was kept at the entrance or front desk. Further review revealed that a staffing data sheet was present but hidden behind a blank sheet, making it not visible to the public. Facility leadership acknowledged that the staffing data should be posted and visible daily in an accessible location for residents and visitors.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and beverage items served to residents were safe and at appetizing temperatures. Resident Council minutes over several months documented ongoing concerns from residents about receiving cold food upon delivery, with repeated complaints about inconsistent food temperatures and dissatisfaction with meal quality. During interviews, the President of the Resident Council confirmed that residents continued to report that hot foods were being served cold and described the food as awful. Observations during breakfast and lunch meal services revealed that kitchen staff had difficulty keeping plate covers properly fitted over food trays. Plate covers frequently slid off or were not used correctly, resulting in food being left uncovered during transport to resident units. The facility did not have enough proper plate covers, leading staff to use two plate bottoms or only a single cover, which did not adequately maintain food temperatures. Temperature checks conducted by the Food Service Director and surveyor on delivered trays showed that both hot and cold food items were not at appropriate temperatures upon arrival to residents. For example, scrambled eggs and oatmeal were below the required hot holding temperature, while milk and juice were above the recommended cold holding temperature. The Food Service Director acknowledged that the food and beverage items were not at correct temperatures and attributed some of the issues to a lack of sufficient plate covers.
Failure to Properly Store, Label, and Discard Food in Nourishment Kitchenettes
Penalty
Summary
The facility failed to ensure that food items in two nourishment kitchenettes were stored, prepared, and served in accordance with professional standards and facility policy. Observations revealed that both Main 1 and Main 2 nourishment kitchenettes contained expired food items, unlabeled and undated beverages and foods, and visible dirt and sticky substances on refrigerator and freezer surfaces. Items such as pre-made lemonade, pudding, yogurt, and various beverages were found past their expiration dates, and several food items lacked required labeling with names and dates. Additionally, some food packages were not properly sealed, and personal staff items were found in resident-designated refrigerators, contrary to facility policy. Interviews with the Food Service Director (FSD) and Director of Nursing (DON) confirmed that dietary staff were responsible for cleaning and discarding expired food twice daily, with the FSD conducting weekly random audits. However, the presence of trash, dirty surfaces, and expired or improperly labeled food indicated that these procedures were not consistently followed. The FSD and DON both stated that staff were not permitted to store personal food or beverages in the resident kitchenettes, yet a CNA was observed attempting to do so. Facility policies required all food and beverages to be labeled with names and dates, with items discarded after three days in the refrigerator. The policies also specified that refrigerators should be cleaned daily and that only resident food items were permitted. Despite these clear guidelines, the surveyor's findings demonstrated multiple instances of non-compliance, including expired manufactured food, unsealed packages, and unsanitary conditions in both kitchenettes.
Failure to Document Hospital Transfer and Return in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who experienced an acute hospital transfer and subsequent return. On the date in question, there was no nursing documentation regarding the resident's change in condition, the assessment prior to transfer, physician notification, or details of the hospital transfer and return. The facility's policy requires supporting documentation for all diagnoses and changes in a resident's status, including evaluations, indications of distress, and changes in functional status, but this was not followed in this instance. The resident involved had multiple diagnoses, including Parkinson's Disease, Atrial Fibrillation, Asthma, Depression, Anxiety Disorder, Paranoid Disorder, muscle weakness, difficulty walking, and lack of coordination, and was cognitively intact. The resident reported experiencing numbness and weakness in one arm, which led to calling EMS and being transferred to the hospital. The nurse on duty was unaware of the transfer until after it occurred and did not assess the resident, communicate with EMS, or document the event in the medical record. The DON confirmed that documentation of the transfer and return was expected but not completed.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to adhere to its own policy and procedures regarding abuse prohibition by not conducting Massachusetts Nurse Aide Registry background checks for three employees prior to their hire. The policy mandates thorough investigations into the histories of prospective staff, including checking the state nurse aide registry to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. However, the personnel files for Nurse #1, Nurse #4, and Certified Nurse Aide #3 showed no documentation of such checks being conducted before their employment. During an interview, the Human Resource Director, who was responsible for conducting pre-hire background checks since August 2024, admitted to not being trained in conducting Massachusetts Nurse Aide Registry checks. Consequently, she had not been performing these checks, and was unable to provide documentation to support that the required background checks were conducted for the three employees in question. This oversight indicates a failure to follow established procedures designed to prevent abuse, neglect, and exploitation within the facility.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to provide a safe environment free from abuse for a resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain. The resident reported incidents involving a CNA who allegedly handled them roughly during care. The resident described being aggressively moved from a sitting position to the bed, causing shoulder pain, and experiencing rough handling during a shower, which they perceived as a violation of personal boundaries. The Assistant Director of Nurses (ADON) acknowledged awareness of the resident's concerns but managed them as customer service issues rather than abuse allegations. The ADON provided an inservice for staff, excluding the involved CNA, focusing on the resident's care preferences. Despite the resident's family filing a formal complaint, the facility did not follow through with a thorough investigation or report the incidents to the Administrator, state agency, or local law enforcement. The facility's policy mandates reporting and investigating abuse allegations, but the Administrator was not informed of the incidents. The lack of documentation, witness statements, and incident reports indicates a failure to adhere to the facility's abuse policy. The resident expressed ongoing pain and emotional distress, feeling that their concerns were not adequately addressed by the facility.
Failure to Implement Abuse Policy and Report Allegations
Penalty
Summary
The facility failed to implement its abuse policy for a resident, leading to a deficiency in handling allegations of abuse. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) did not notify the Administrator about allegations of physical, sexual, and mental abuse involving a resident. The resident, who had intact cognition and was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain, reported being handled roughly by a Certified Nurse's Assistant (CNA). The resident's family also reported these concerns to the DON, but the allegations were not communicated to the Administrator. The facility did not take immediate action to protect the resident by suspending the staff member involved in the abuse allegations. Despite the resident's complaints of being thrown onto a bed and being bathed roughly, the CNA continued to be assigned to the resident. The ADON acknowledged awareness of the concerns but managed them as customer service issues rather than abuse allegations, failing to follow the facility's policy of immediate suspension pending investigation. Furthermore, the facility did not report or investigate the abuse allegations as required. The DON and ADON did not complete necessary documentation, such as incident reports, witness statements, or evaluations, and did not maintain a timeline of events. The allegations were not reported to the state agency or local law enforcement within the required two-hour timeframe, as per the facility's policy. The Administrator was unaware of the allegations, indicating a breakdown in communication and protocol adherence within the facility.
Failure to Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain. The resident, with intact cognition, reported two incidents involving a Certified Nurse's Assistant (CNA). In the first incident, the resident alleged that the CNA bathed them roughly, forcefully spreading their legs and scrubbing aggressively, despite the resident's request to wash themselves. The resident felt this was a form of sexual assault and reported the incident to the Director of Nurses (DON) and their family. In the second incident, the resident claimed that the same CNA aggressively moved them from a sitting position on the bed, causing shoulder pain. The resident was in a comfortable sleeping position when the CNA allegedly threw them onto the bed. The resident's family was informed of both incidents and reported them to the DON, expressing concerns about retaliation as the CNA was assigned to the resident again after the first incident. Despite the facility's policy requiring immediate reporting of abuse allegations to the state agency and law enforcement within two hours, these incidents were not reported. Interviews with the Assistant Director of Nurses (ADON) and the Administrator confirmed awareness of the incidents but indicated they were managed as customer service issues rather than abuse allegations. A review of the Health Care Facility reporting system showed no abuse allegations were reported during the relevant period.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse for a resident, leading to a deficiency in their care. The resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain, reported two incidents involving a Certified Nurse's Assistant (CNA). The resident claimed that the CNA had aggressively handled them during a transfer and bathed them roughly, causing discomfort and pain. Despite the resident's intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, their complaints were not properly addressed by the facility. The resident reported these incidents to the Director of Nurses (DON) and their family members, who also communicated the concerns to the DON. However, the facility treated these serious allegations as customer service issues rather than potential abuse cases. The Assistant Director of Nurses (ADON) acknowledged awareness of the complaints but did not initiate a formal investigation as required by the facility's policy. This policy mandates a thorough investigation of any abuse allegations, including documentation, witness statements, evaluations, and a timeline of events, none of which were completed. Interviews with the facility's staff, including the Administrator, ADON, and DON, confirmed that no incident reports were initiated, and no formal investigation was conducted following the resident's allegations. The Unit Manager, who participated in an abuse/neglect in-service, was also unaware of the details of the allegations, indicating a lack of communication and adherence to protocol within the facility. This failure to investigate and document the allegations of abuse constitutes a significant deficiency in the facility's care and response procedures.
Failure to Conduct Controlled Substance Count at Shift Change
Penalty
Summary
The facility failed to ensure that nursing staff implemented standards of practice by not conducting the required controlled substance count at the time of a shift change on one of the resident care units. According to the facility's policy, controlled substances must be reconciled at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count and documenting it in the controlled substance logbook. However, on the morning of June 10, 2024, Nurse #2, who worked the night shift, did not perform the narcotic count with the incoming day shift nurse, Nurse #1. Nurse #2 left the floor without completing the count, and the controlled substance logbooks on both medication carts were not properly filled out, with missing entries for the status of the count and the name of the incoming nurse. During interviews, Nurse #1 confirmed that the narcotic count was not completed as required, and Nurse #2 admitted to leaving the floor without conducting the count. The Director of Nursing reiterated that both nurses are responsible for performing the controlled substance count and documenting it during shift changes. This lapse in procedure was observed and documented by surveyors, highlighting a failure to adhere to the facility's policy on controlled substance management, which is crucial for maintaining accurate dispensing and inventory of these medications.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at appetizing temperatures. During a resident group meeting, residents expressed ongoing dissatisfaction with the food, describing it as unappetizing and often served at incorrect temperatures. Observations during meal service on two separate days confirmed these complaints. Meals were found to be either too cold or too warm, with hot items not served hot and cold items not served cold. Additionally, the meals lacked condiments, and the food was described as bland and mushy. The surveyor's test trays on both days revealed similar issues, with food items such as tuna noodle casserole, sliced carrots, and pork loin with gravy being served at inadequate temperatures. The food was often described as mushy, bland, and lacking in flavor. Beverages like coffee and apple juice were not served at appropriate temperatures, and there were no condiments provided with the meals. The food service manager acknowledged that the food should be palatable and served at the correct temperatures, but the observations indicated a failure to meet these standards.
Failure to Implement QAPI Plan and Ensure Adequate RN Staffing
Penalty
Summary
The facility failed to implement its Quality Assurance Performance Improvement (QAPI) plan during a leadership transition, which resulted in deficiencies in staffing and quality of care. Specifically, the facility did not identify or develop a plan for services provided by Registered Nurses (RNs) and failed to ensure that the Director of Nursing (DON) was not working as a charge nurse. The facility's QAPI plan, which was intended to improve care and services through Performance Improvement Projects (PIPs), was not effectively utilized to address these issues. The facility's Payroll-Based Journal Staffing Data Report indicated a one-star staffing rating due to insufficient RN staffing, as the facility reported seven or more days in a quarter with no RN hours. This staffing deficiency was not addressed in the QAPI meetings, and no PIP was developed to rectify the lack of RN services. The DON was documented to have worked multiple shifts as a charge nurse, which was not identified as a concern by the facility's administration. The Administrator, who started in late April 2024, acknowledged the oversight and the need for a PIP to address the staffing issues.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of tracking and trending of infections within the facility. The Director of Nursing (DON) admitted during an interview that she was responsible for the implementation and monitoring of the infection control program but did not complete the necessary monitoring, tracking, and trending of infections for March, April, and May 2024. Furthermore, the facility did not have a policy in place for tracking and trending infections, as confirmed by the DON. Additionally, the facility did not implement a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water systems. The facility's policy, dated May 1, 2018, outlined the need for a water management program to reduce risks from Legionella bacteria. However, during an interview, the Maintenance Director revealed that the facility had not implemented the water management program, nor had it conducted any water assessments or implemented necessary measures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship Program effectively, as evidenced by the lack of monitoring and tracking of antibiotic use. The policy titled 'Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes' required that antibiotic usage and outcome data be collected and documented using a facility-approved tracking form. This data was intended to guide decisions for improving individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. However, the Director of Nursing (DON), who was responsible for the implementation and monitoring of the program, admitted during an interview that she did not complete the necessary monitoring, tracking, and trending of antibiotic use as per the facility's policy.
Medication Administration and Physician Order Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for four residents, resulting in deficiencies in medication administration and adherence to physician orders. For three residents, medications were not administered as ordered, with no documentation or explanation provided in the medical records. Specifically, Resident #63 did not receive multiple medications for conditions such as atrial fibrillation, hypertension, and kidney transplant complications on specified dates. Similarly, Resident #69 did not receive their cholesterol medication, and Resident #27 missed doses of epilepsy and diabetes medications. In addition to medication administration issues, the facility failed to follow a physician's order regarding the re-evaluation of a temporarily invoked health care proxy for Resident #54. The physician had ordered a re-evaluation to determine if the health care proxy should remain invoked, but the facility did not complete the necessary assessment. The Director of Rehab indicated that a MoCA assessment was not conducted, and the resident had not been seen by a neurologist as required. These deficiencies highlight a lack of adherence to professional standards and physician orders, impacting the care and treatment of the residents involved. The absence of proper documentation and follow-through on medical orders raises concerns about the facility's ability to provide consistent and reliable care to its residents.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to maintain sufficient staffing levels to provide adequate resident care on two units, as evidenced by record reviews and interviews. The Facility Assessment Tool did not include a completed staffing plan for Nurses' Aides and Licensed nurses, and the Payroll-Based Journal Staffing Data Report indicated excessively low weekend staffing. Residents reported long wait times for assistance, particularly during the evening shift, and expressed concerns about insufficient staff to meet their needs, especially on weekends. Interviews with staff confirmed that the facility often operated with fewer CNAs than required, impacting the timeliness of care and medication administration. The facility's scheduler acknowledged staffing shortages, particularly on weekends, and noted that efforts to cover shifts were sometimes unsuccessful. The working schedules for April, May, and June 2024 showed multiple instances where the facility operated with fewer CNAs than planned, particularly on the first-floor unit. Staff interviews revealed that while they attempted to manage with reduced numbers, the lack of adequate staffing made it challenging to provide timely and comprehensive care to residents, especially those with memory loss on the second floor.
Deficiency in RN Staffing and DON Role
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for a minimum of eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the facility's 'Payroll-Based Journal Staffing Data Report' for the second quarter of 2024, which indicated a one-star staffing rating due to insufficient RN coverage. The facility did not report any nursing staffing waivers, and the Administrator, who started in late April 2024, was unaware of the lack of RN coverage. Additionally, the Director of Nursing (DON) was found to be working as a charge nurse, covering various shifts due to staffing shortages. The DON worked several night shifts and other shifts, which conflicted with her responsibilities as the Director of Nursing. During interviews, the DON expressed that she had no choice but to cover these shifts to ensure resident care, despite having other duties as the DON. This situation contributed to the facility's failure to meet the required RN staffing levels.
Failure to Address Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for three residents. Resident #34, who was admitted with diagnoses including diabetes, high blood pressure, and dementia, was prescribed an antipsychotic medication without a supporting diagnosis. The pharmacist recommended clarifying the diagnosis and adjusting the medication duration according to CMS guidelines. However, the physician delayed adding the necessary diagnosis and discontinuing the PRN antipsychotic, resulting in the medication being administered beyond the 14-day limit without review. Resident #59, admitted with bipolar disorder and dementia, was receiving Divalproex (Depakote) without recent serum level monitoring. The pharmacist recommended obtaining a serum level, but the lab was not drawn until over a month later. This delay in following the pharmacist's recommendation indicates a lack of timely response to medication management needs. Resident #46, with dementia and delusional disorders, was receiving Quetiapine for agitation without recent attempts to taper the dosage. The pharmacist recommended a trial taper, which the physician agreed to, but the facility did not implement the changes promptly. The medication continued to be administered at the original dosage, highlighting a failure to act on agreed-upon recommendations. Interviews with the DON and the physician confirmed that recommendations should be implemented within 24 hours, but this was not done for the residents involved.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that resident issues raised during Resident Council Meetings were addressed and resolved. The facility's policy on grievances, revised in March 2021, mandates that grievances be addressed by the Grievance Official and resolved collaboratively with team members, with written decisions provided to the resident or their family. However, a review of the Resident Council Meeting Agenda from March 2024 revealed several unresolved quality of care issues, including missing condiments on meal trays, lack of milk, being left alone in the shower, and call lights not being answered at night. These concerns were not logged as grievances, and the section for old business issues on the April 2024 agenda was left blank, indicating a lack of follow-up on previously raised concerns. During a resident group meeting in June 2024, residents reiterated ongoing issues such as the absence of condiments, untimely response to call lights, and insufficient staffing affecting shower schedules. The Activity Director, who assists with the meetings, admitted that concerns were communicated verbally to department heads but not documented on grievance forms. Additionally, a meeting was missed in May 2024 due to a non-functional elevator, further hindering the resolution process. This lack of documentation and follow-up demonstrates a failure to adhere to the facility's grievance policy and address resident concerns effectively.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #42, admitted with diagnoses including morbid obesity, heart disease, and anemia, experienced a significant weight loss of 10.63% over a one-month period. However, the MDS assessment did not reflect this unplanned weight loss, as confirmed by the MDS Nurse who acknowledged the oversight. The Assistant Director of Nursing also expressed an expectation for the MDS to be accurate, highlighting a lapse in the documentation process. Similarly, Resident #71, admitted with multiple fractures, cerebrovascular disease, and anxiety disorder, was observed to have dental issues, including missing, broken, and carious teeth. Despite these observations and the resident's own acknowledgment of dental problems, the MDS assessment inaccurately reported no dental issues. The MDS Nurse admitted to mistakenly documenting the resident's dental status, which should have included the presence of broken and carious teeth. This discrepancy was also noted by the Assistant Director of Nursing, who reiterated the expectation for accurate MDS documentation.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident with a history of suicidal ideations and alcohol abuse. The facility's policy requires individualized care plans with measurable objectives and timetables to address each resident's medical, nursing, emotional, and psychological needs. However, for one resident, the care plan did not include personalized plans for managing their history of suicidal ideation and alcohol abuse, despite these issues being documented in the resident's behavioral services therapy notes. The resident, admitted with a diagnosis of depression, had a moderately impaired cognition score and a history of mood disorder with severe episodic angry outbursts. The resident had been hospitalized for expressing suicidal thoughts, although they later claimed not to have meant it. Despite being sober for several years, the resident's history of alcohol abuse was noted. Interviews with the Licensed Mental Health Counselor and the Director of Nurses confirmed that care plans addressing these issues should have been developed, but were not.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to provide necessary hearing services for a resident with hearing loss, dementia, and adult failure to thrive. The resident was admitted in June 2022 and had moderate difficulty hearing, requiring speakers to raise their voices. A doctor's progress note from January 2024 indicated a family concern about the resident's decreased hearing, noting that the resident could not pass the whisper test even with hearing aids. The doctor recommended an audiologist evaluation, but no order for an audiology appointment was found in the medical records. A follow-up note in March 2024 reiterated the need for an audiologist evaluation, yet no appointment was made. By June 2024, the Assistant Director of Nursing confirmed that no audiology consult had been arranged, and the facility could not produce a policy for audiology consults upon the surveyor's request.
Failure to Conduct Required Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to implement risk assessments and skin evaluations for the prevention of pressure ulcers for a resident. The facility's policy required a risk assessment to be conducted within eight hours of admission and repeated weekly for the first four weeks or as needed based on the resident's condition. However, for a resident admitted in May 2024 with conditions including chronic atrial fibrillation, hemiplegia, hemiparesis, and dementia, the facility did not follow these guidelines. The resident was identified as having moderately impaired cognition and was dependent on staff for daily activities, making them at risk for developing pressure ulcers. Despite being at high risk, as indicated by a Norton Scale score of 10.0, the resident's medical record showed no further skin risk assessments after the initial one. Interviews with nursing staff revealed that weekly skin assessments were not conducted as required, and the necessary physician's order for these assessments was not entered upon admission. This oversight resulted in five weeks of missed weekly skin checks for the resident, highlighting a significant lapse in the facility's adherence to its own pressure injury prevention policy.
Failure to Label G-tube Feeding Bags Appropriately
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube) by not labeling the enteral formula bag and water flush bag with necessary information. The resident, who was admitted with diagnoses including dysphagia, encephalopathy, and legal blindness, required feeding by tube and was not able to take anything by mouth. The facility's policy required that the formula label document initials, date, and time the formula was hung/administered, and that the label was checked against the order. However, during observations, the surveyor noted that the G-tube feeding bag and the water flush bag lacked labels containing the resident's name, the formula used, the administration rate, duration, and initials of the staff member hanging them. The surveyor observed on two separate occasions that the bags were not properly labeled according to the facility's policy. On one occasion, the bags were observed without a label containing the resident's name, the contents of the bag, the date and time formula was hung/administered, or initials indicating that the label was checked against the order. On another occasion, the bags were dated and timed but still lacked the resident's name, the contents of the bag, or initials. During an interview, a nurse confirmed that the contents of the tube feeding bag and the water bag should be indicated on the bags, highlighting the facility's failure to adhere to its own policy and ensure proper labeling of the feeding equipment.
Failure to Re-evaluate Psychotropic Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure that psychotropic medications were re-evaluated after 14 days of use for two residents, leading to a deficiency in medication management. Resident #34, who was admitted with diagnoses including diabetes, high blood pressure, and dementia, was prescribed Seroquel as needed without a stop date. Despite a pharmacist's recommendation to discontinue the PRN antipsychotic after 14 days, the medication was administered beyond this period without a doctor's review. The Director of Nursing acknowledged that PRN antipsychotic use must be evaluated every 14 days, but this protocol was not followed. Similarly, Resident #46, admitted with dementia and delusional disorders, had an active order for Quetiapine PRN with a duration of 100 days, contrary to CMS guidelines. Despite multiple requests from the pharmacist to discontinue or adjust the duration, the medication was administered beyond the 14-day limit. The physician agreed with the pharmacist's recommendations but did not ensure timely implementation. The Director of Nurses confirmed that agreed-upon recommendations should be enacted promptly, but this was not done, resulting in continued administration of the medication without proper evaluation.
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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