Maristhill Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waltham, Massachusetts.
- Location
- 66 Newton Street, Waltham, Massachusetts 02453
- CMS Provider Number
- 225408
- Inspections on file
- 19
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Maristhill Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident sustained a second-degree burn on the forehead when a CNA used a personal curling iron to style the resident's hair, contrary to facility policy. The incident was not immediately reported, and the burn was discovered the next day. The CNA was unaware that using personal electric devices was against policy and outside her scope of practice.
The facility failed to follow wound care orders for three residents, leading to deficiencies in pressure ulcer management. One resident with a stage 4 ulcer was not using prescribed pressure relief boots, another with severe cognitive impairment had a boot misplaced, and a third had wound care orders not transcribed into the TAR, resulting in inconsistent treatment.
Improper food handling practices were observed in the facility, with staff failing to follow sanitation protocols. Servers and the FSD were seen using potentially contaminated gloves to handle food, violating the facility's policy on glove use and hand hygiene. Despite training, these lapses in procedure were noted during meal service observations.
A facility failed to report a resident's abuse allegations within the required two-hour timeframe. The resident reported mistreatment by a CNA, including excessive TV volume and denial of care. Despite being informed, the DON delayed reporting to the state agency for over 24 hours, citing a lack of immediate feedback from the social worker who investigated the claims.
A facility failed to accurately complete a Level 1 PASARR for a resident with schizotypal disorder, a serious mental illness, resulting in the omission of a required Level II evaluation. The facility's policy requires screening for mental disorders upon admission, but the PASARR incorrectly indicated no mental illness. Interviews revealed that the PASARR form is completed by an external nurse, with the social worker as a backup, and both the social worker and DON acknowledged the error.
A facility failed to create a comprehensive care plan for a resident with a pacemaker, omitting crucial details such as the paced rate, serial number, and cardiologist information. The resident reported heart fluttering and a lack of recent pacemaker checks, which the Unit Manager was unaware of. The DON confirmed that a care plan should have been in place upon admission.
A resident with dementia and edema was observed multiple times without prescribed Teds stockings, despite physician orders and documentation indicating they were applied. Interviews with staff confirmed the oversight, highlighting a deficiency in following professional standards of practice.
A resident with chronic congestive heart failure and bradycardia, who was dependent on staff for all ADLs, did not receive scheduled weekly showers, only bed baths, despite expressing a desire for showers. Staff assumed the resident did not want showers and stopped offering them, contrary to facility policy. Interviews with staff revealed a lack of adherence to the shower schedule and documentation of refusals.
A resident with moderate cognitive impairment had a bruise on their upper left arm that went unnoticed by staff, despite facility policies requiring regular skin assessments and daily inspections. The bruise was discovered by a surveyor, and staff interviews revealed that the CNA responsible for the resident's care was unaware of the injury, which should have been reported to the nurse. The DON confirmed that new skin conditions should be reported immediately.
A facility failed to ensure a resident consistently used hearing aids, despite being cognitively intact and having adequate hearing with them. Observations showed the resident without hearing aids, which were left in the charger. Interviews revealed inconsistencies in staff assistance and documentation regarding the use of hearing aids, contrary to facility policy.
A resident with heart failure and COPD did not receive oxygen therapy as per physician's orders, with observations showing incorrect flow rates and empty oxygen tanks. Despite care plans specifying 1L/min oxygen, the resident was often given 2L/min. Elevated CO2 levels were noted, and a nurse's attempt to wean the resident off oxygen was not in line with orders. The DON confirmed the need to follow physician's directives.
A facility failed to create a trauma-informed care plan for a resident with PTSD, despite the resident's intact cognitive status and diagnosis. The resident's medical record lacked documentation related to PTSD, and no individualized care plan was developed. Social workers admitted they do not inquire about PTSD history to avoid discomfort, and both social workers and the DON agreed that the resident would benefit from a care plan addressing PTSD triggers.
The facility failed to maintain accurate medical records for a resident with dementia and edema. The resident was observed without ted stockings, although the TAR indicated they were worn. Nurses signed off on the TAR, suggesting completion of the task, which was not done. Interviews with the Unit Manager and DON confirmed this documentation error.
A facility failed to assess and offer a pneumococcal vaccination to a resident as per CDC guidelines. The resident, admitted with conditions including pneumonia and COPD, had no documentation of being offered the vaccine. Interviews with staff revealed that the MDS Nurse and Infection Control Nurse did not follow procedures, and the DON acknowledged the lapse in assessing and documenting the resident's vaccination status.
Resident Burned by Unauthorized Use of Curling Iron
Penalty
Summary
The facility failed to ensure the safety of a resident during personal care, resulting in a second-degree burn. A Certified Nurse Aide (CNA) used an electric curling iron to curl the resident's hair, which led to the resident sustaining a burn on the upper left side of the forehead. The facility's policy on electric safety for residents, which aims to protect residents from injuries associated with electric devices, was not adhered to in this instance. The resident, who was admitted to the facility with conditions including polyosteoarthritis, hypertension, and atrial fibrillation, required staff assistance with personal hygiene. Despite being alert and oriented, the resident was unable to independently carry out activities of daily living. On the day of the incident, the CNA brought her personal curling iron to work and used it on the resident's hair, resulting in the burn. The CNA was unaware that bringing personal electric devices into the facility was against policy and not within her scope of practice. The incident was not immediately reported or noticed by the staff, as the burn was discovered the following day by a nurse who observed redness and peeling skin on the resident's forehead. The resident confirmed that the burn occurred when the curling iron touched the forehead. The facility's Director of Nursing later confirmed that the CNA's actions were outside the scope of practice and against facility policy, which only allows CNAs to wash, towel dry, and comb residents' hair.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to implement treatment orders recommended by the Wound Physician for three residents, leading to deficiencies in pressure ulcer care. Resident #74, who was admitted with a stage 4 pressure ulcer on the right heel, was observed multiple times with heels directly on the bed, despite orders for pressure relief boots. The resident, cognitively intact, confirmed not wearing the boots, and staff interviews revealed a lack of adherence to the physician's recommendations. Resident #40, with severe cognitive impairment and a stage 3 pressure ulcer, was also observed with heels directly on the mattress, contrary to the physician's order to offload the right heel using a foam boot. The boot was found behind the television, and staff were unaware of the requirement to use it, indicating a failure to follow the prescribed treatment plan. Resident #55, with moderate cognitive impairment and a stage 2 pressure ulcer, had a physician's order for specific wound care that was not transcribed into the Treatment Administration Record (TAR). This oversight resulted in inconsistent implementation of the wound care order, as confirmed by staff interviews, highlighting a lapse in documentation and treatment adherence.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices were followed by staff, leading to potential contamination of food and an increased risk of foodborne illness. Observations on the third-floor unit during breakfast and lunch meals revealed multiple instances of improper glove use by servers and the Food Service Director (FSD). Staff members were seen changing gloves without washing hands in between, touching various surfaces and utensils with potentially contaminated gloves, and handling food directly with bare hands. These actions were in direct violation of the facility's policy, which mandates that bare hands must not touch ready-to-eat food and that gloves must be discarded after each use, with handwashing required before and after glove use. During interviews, the FSD acknowledged the importance of hand hygiene and stated that training is consistently provided to kitchen staff. However, the observed practices demonstrated a lack of adherence to these protocols. The FSD also confirmed that once gloves come into contact with objects other than food, they are considered contaminated and should not be used to handle food. Despite this understanding, both the FSD and other staff members were observed handling food with potentially contaminated gloves, indicating a significant lapse in following established food safety procedures.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe for one resident. On the morning of October 8, 2024, the Director of Nursing (DON) was informed of a resident's allegations of mistreatment by a certified nursing assistant (CNA). The resident reported that the CNA would raise the television volume excessively and close the window blinds without consent, actions perceived as controlling. Additionally, the resident mentioned being denied assistance with incontinence care, which reminded them of previous mistreatment at another facility. Despite being informed of these allegations, the DON did not report them to the state agency until over 24 hours later, following an inquiry by a surveyor. The facility's policy mandates that any knowledge of abuse allegations must be reported to the Department of Public Health within two hours. However, the DON delayed reporting, citing that the social worker was sent to follow up with the resident but did not immediately report back. The social worker admitted to interviewing the resident but was unsure how to document the findings, contributing to the delay. This inaction resulted in a failure to comply with the facility's policy and state regulations regarding timely reporting of abuse allegations.
Failure to Complete Accurate PASARR Screening for Resident with SMI
Penalty
Summary
The facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of schizotypal disorder, which is classified as a serious mental illness (SMI). This oversight resulted in the necessary Level II PASARR evaluation not being conducted as required. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disorders, or related disorders through the PASARR process. If the Level 1 screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is required. However, for this resident, the Level 1 PASARR incorrectly indicated no documented diagnosis of a mental illness, despite the resident's active diagnosis of schizotypal disorder. Interviews with facility staff revealed that the PASARR form is typically completed by an external nurse, with the facility's social worker serving as a backup to ensure completion prior to admission. The social worker acknowledged that the PASARR should have been accurately completed given the resident's diagnosis of a serious mental illness. The Director of Nursing also confirmed that the Level 1 PASARR should have been documented correctly upon the resident's admission. This failure to accurately complete the PASARR process highlights a lapse in the facility's adherence to its own admission criteria and screening procedures.
Failure to Develop Comprehensive Pacemaker Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with a pacemaker, leading to a deficiency. The resident, who was admitted with diagnoses including heart failure and the presence of a cardiac pacemaker, did not have a care plan that included essential pacemaker information such as the paced rate, serial number, frequency of pacemaker checks, and cardiologist contact details. This omission was identified during a review of the resident's physician orders and care plans, which lacked these critical details. The deficiency was further highlighted during interviews with the resident and facility staff. The resident reported experiencing heart fluttering and noted that the pacemaker had not been checked recently. The Unit Manager was unaware of the resident's symptoms and acknowledged the absence of a care plan with the necessary pacemaker information. The Director of Nursing confirmed that a pacemaker care plan should have been established upon admission, including all relevant details to ensure proper monitoring and care.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident who was admitted with diagnoses including dementia, instability of the left knee, and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. The physician's orders required the application of Teds (compression) stockings to both legs while the resident was out of bed once a day for edema management. However, on multiple occasions throughout the day, the surveyor observed the resident without the prescribed Teds stockings, indicating a failure to adhere to the physician's orders. The Treatment Administration Record (TAR) for the specified date was signed off, incorrectly indicating that the Teds stockings had been applied. Interviews with the Unit Manager and the Director of Nursing confirmed that the physician's orders should have been followed, and the resident should have been wearing the Teds stockings as prescribed. This discrepancy between the documented care and the observed care highlights a deficiency in the facility's adherence to professional standards of practice.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs) for a dependent resident, specifically failing to provide weekly showers. The resident, who was admitted with chronic congestive heart failure and bradycardia, was found to have intact cognition and was dependent on staff for all ADLs. Despite being scheduled for weekly showers, the resident only received bed baths over the past 31 days and expressed a desire for showers if deemed safe by staff. The facility's policy indicated that residents should receive frequent showers or baths, and the resident's care plan included providing sponge baths only when a full bath or shower could not be tolerated. Interviews revealed that staff had stopped offering showers to the resident, assuming they were not wanted, despite the resident's willingness to have them. A CNA admitted to not asking the resident about their preference for showers, and a nurse confirmed that residents should be offered showers weekly. The Director of Nursing stated that all residents should be offered showers weekly, and any refusals should be documented. The lack of documentation of refusals and failure to follow the shower schedule contributed to the deficiency.
Failure to Identify and Report Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident with moderate cognitive impairment, who was admitted with diagnoses including unspecified dementia and anxiety disorder. The deficiency was identified when a surveyor observed a round, purple mark with yellow edging on the resident's upper left arm, which the resident was unaware of. The resident mentioned a fall about a week prior, but staff had not informed them about the bruise. The facility's policy required comprehensive skin assessments and daily skin inspections, yet the most recent skin check evaluation and physician's progress note did not document any abnormalities or bruising. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the bruise and acknowledged that it should have been reported to the nurse. The nurse confirmed that such marks should be identified during activities of daily living (ADL) care. The Director of Nursing (DON) stated that CNAs are expected to report new skin conditions immediately for investigation. The failure to identify and report the bruise indicates a lapse in the facility's adherence to its skin assessment and reporting protocols.
Failure to Ensure Consistent Use of Hearing Aids for a Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing and utilize assistive devices for communication. Specifically, the facility did not consistently implement the use of hearing aids for a resident who was admitted with cognitive and cardiac conditions. The resident was cognitively intact and had adequate hearing with the use of hearing aids, as indicated in the Minimum Data Set assessment. However, during multiple observations, the resident was found not wearing the hearing aids, which were left in the charger on the television stand. Interviews with the resident and staff revealed inconsistencies in the assistance provided for wearing hearing aids. The resident mentioned that staff sometimes assisted with the hearing aids, while the Unit Manager and Director of Nursing indicated that CNAs or nurses should assist and document any refusal to wear the aids. The medical record did not show any documentation of the resident refusing to wear the hearing aids, indicating a lapse in following the facility's policy for assisting hearing-impaired residents.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy, as per the physician's order. The resident, diagnosed with acute systolic congestive heart failure and chronic obstructive pulmonary disease (COPD), was observed multiple times receiving oxygen at an incorrect flow rate of 2 liters per minute, contrary to the physician's order of 1 liter per minute. Additionally, the resident was found using an empty portable oxygen tank on two occasions, indicating a lack of proper monitoring and management of the resident's oxygen supply. The resident's care plans for congestive heart failure and COPD both specified oxygen therapy at 1 liter per minute, yet observations revealed discrepancies in the administration of oxygen. The resident's lab results also showed elevated carbon dioxide levels, which were flagged as high. During an interview, a nurse mentioned attempts to wean the resident off oxygen due to CO2 retention, but this was not aligned with the physician's orders. The Director of Nursing confirmed that the physician's orders should have been followed, highlighting a failure in adhering to prescribed respiratory care protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in May 2024, had a diagnosis of PTSD and an unspecified mood disorder. Despite having an intact cognitive status as indicated by a perfect score on the Brief Interview for Mental Status, the resident's medical record lacked documentation related to the PTSD diagnosis. Furthermore, the active care plans did not include an individualized care plan addressing the PTSD diagnosis with specific interventions or approaches. Interviews with the facility's social workers revealed that although residents are assessed during admission, they do not inquire about a resident's PTSD history to avoid discomfort. The social workers acknowledged that the resident would benefit from a care plan with individualized interventions and approaches related to PTSD triggers. The Director of Nursing also confirmed that the resident should have an individualized PTSD care plan with specific interventions and approaches for managing PTSD triggers.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #55, who was admitted with diagnoses including dementia and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. On two separate occasions, the surveyor observed the resident in bed without ted stockings, despite the Treatment Administration Record (TAR) indicating that the resident was wearing them. The TAR for the morning of the observation was signed off by nurses, suggesting the task was completed when it was not. Interviews with the Unit Manager and the Director of Nursing confirmed that nurses should not document tasks as completed if they were not performed.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to assess and offer pneumococcal vaccinations to a resident as per CDC recommendations. The policy in place required that residents be assessed for eligibility and offered the vaccine within 30 days of admission unless contraindicated or previously vaccinated. However, for one resident, who was admitted with diagnoses including pneumonia, COPD, heart failure, and dementia, there was no documentation in the medical records to indicate that the pneumococcal vaccine was offered or administered. The resident's Minimum Data Set assessment also lacked information on the vaccination status. Interviews with facility staff revealed lapses in following the established procedures. The MDS Nurse admitted to not having documentation to support that the resident was offered the vaccine, and the Infection Control Nurse confirmed that the resident was not assessed or offered the vaccine upon admission. The Director of Nursing acknowledged that the nursing staff should have assessed the resident's eligibility for the pneumococcal vaccine and documented it in the medical record.
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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