Marlborough Hills Rehabilitation & Health Care Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Marlborough, Massachusetts.
- Location
- 121 Northboro Road, Marlborough, Massachusetts 01752
- CMS Provider Number
- 225063
- Inspections on file
- 22
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Marlborough Hills Rehabilitation & Health Care Cen during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and total dependence on staff for transfers was moved from bed to wheelchair by two CNAs without the required mechanical lift, despite clear care plan instructions. Both CNAs were aware of the transfer requirements but did not follow them, and the incident was observed by a nurse.
A resident with a history of suicidal ideations and self-injurious behavior repeatedly gained access to metal utensils and attempted self-harm, despite care plan interventions such as plastic utensils, staff supervision, and periodic monitoring. The facility did not revise the care plan to effectively prevent the resident from obtaining potentially harmful items after multiple incidents.
A resident with a history of suicidal ideation and moderate cognitive impairment was able to access and manipulate metal forks on two occasions, despite care plan interventions requiring only plastic utensils and 1:1 supervision during meals. The resident attempted self-harm with the utensils, and staff were unable to determine how the utensils were obtained or ensure the required supervision was provided.
A resident with a history of suicidal ideation and self-injurious behavior experienced multiple episodes of suicidal behavior, including attempts with utensils, but did not receive timely behavioral psychiatric evaluation or adjustments to their care plan. Communication gaps between nursing staff and the behavioral health provider resulted in delayed intervention, despite repeated hospital transfers for suicidal incidents.
A facility failed to include a resident's Health Care Agent (HCA) in the care planning process, despite the resident's Health Care Proxy being invoked due to moderate dementia. The resident, diagnosed with schizoaffective disorder, anxiety disorder, and bipolar disorder, was admitted in June 2024. The facility did not invite the HCA to the December 2024 care plan meeting, as indicated by blank sections on the Care Plan Meeting Invitation and Interdisciplinary Care Plan Meeting Form. Staff interviews revealed a lack of awareness about the invoked Health Care Proxy, leading to the HCA's exclusion from the care planning process.
The facility failed to obtain written consent and provide education on the risks and benefits of psychotropic medications before administering them to a resident with multiple mental health diagnoses. The resident, who was considered self-responsible, did not sign the consent forms until after the surveyor's inquiry, indicating a lapse in following the facility's policy.
A resident with moderately impaired cognition was not included in the care planning process. The facility failed to hold or document any care plan meetings for the resident since their admission, as confirmed by both the resident and the social worker.
The facility failed to implement a care plan for a resident with Multiple Sclerosis, neglecting to apply a left palm guard as ordered for contracture prevention and skin breakdown. Observations and staff interviews revealed a lack of adherence to the care plan, with staff unaware of the requirement and the resident expressing concern about their condition worsening.
The facility failed to ensure that a resident was weighed weekly as ordered by the physician and recommended by the RD following hospitalization and J-tube placement, resulting in delayed identification of significant weight loss. The resident's weights were not documented on the specified dates, leading to a significant weight loss of 27.4 pounds from October to November.
The facility failed to ensure that pharmaceutical services met the needs of each resident by not re-ordering and replacing emergency medication kits (E-Kits) after they were opened and not completing the required documentation for medications removed from the E-Kits. Several E-Kits were found opened without proper documentation, and there was no evidence that the forms were faxed to the pharmacy to reorder the kits.
The facility failed to store medications securely. Escitalopram, a psychotropic medication, was left unsecured on a desk behind the nurses' station after being delivered from the pharmacy. The Unit Manager acknowledged that the medication should have been locked in the medication room until it could be transferred to the correct nursing unit.
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. One resident's left palm guard was misplaced and not used despite being documented as applied, while another resident's advanced directive records contained conflicting information and an incomplete MOLST form.
Failure to Follow Care Plan for Mechanical Lift Transfers
Penalty
Summary
Staff failed to consistently implement and follow the care plan interventions for a resident who required the assistance of two staff members and a mechanical lift for all transfers. Despite the care plan and care card specifying the use of a Hoyer lift, two CNAs transferred the resident from bed to wheelchair without using the mechanical lift. The incident was directly observed by a nurse, and both CNAs acknowledged in their statements that they did not use the Hoyer lift, even though they were aware of the resident's transfer requirements. The resident involved had diagnoses including Alzheimer's disease, Major Depressive Disorder, and Anxiety Disorder, with moderate cognitive impairment and complete dependence on staff for care needs, positioning, transfers, and mobility. The failure to use the mechanical lift as specified in the care plan was confirmed through interviews, witness statements, and review of the resident's records, demonstrating a lack of adherence to established transfer protocols for this resident.
Failure to Revise Care Plan After Repeated Self-Harm Incidents
Penalty
Summary
A resident with a history of suicidal ideations, major depressive disorder, unspecified dementia, and delusional disorders was admitted to the facility. The resident's care plan included interventions such as providing plastic utensils, frequent staff rounding, weekly psychotherapy, and 1:1 monitoring during meal times. Despite these interventions, the resident was able to access metal utensils on multiple occasions and attempted self-harm, resulting in transfers to the hospital emergency department for evaluation. The care plan was updated after each incident, including the addition of every 15-minute head checks for 72 hours, but the resident continued to obtain items that could be used for self-injury. The facility failed to ensure that the comprehensive care plan was reviewed and revised for effectiveness when the resident continued to gain access to objects used for self-harm. Although some interventions were implemented, there were no additional care plan measures developed or put in place to specifically prevent the resident from obtaining potentially harmful items. Interviews confirmed that the resident was able to access silverware on multiple occasions despite existing care plan interventions.
Failure to Prevent Access to Hazardous Utensils for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident with a history of suicidal ideation and self-harm. Despite care plan interventions specifying the use of only plastic utensils and 1:1 staff supervision during meals, the resident was able to obtain metal forks on two separate occasions. On both occasions, the resident manipulated the metal forks, breaking off prongs and attempting to stab themselves, which resulted in transfers to the hospital emergency department for evaluation. Staff were unable to determine how or when the resident obtained the metal utensils, and the required supervision and monitoring were not effectively implemented. The resident had diagnoses including suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders, and was assessed as having moderate cognitive impairment. The care plan interventions were in place due to the resident's risk for self-harm, but staff failed to prevent access to hazardous items and did not consistently provide the required supervision. Documentation and investigation following the incidents were also incomplete, as acknowledged by the DON, who did not conduct a full written investigation after the second incident.
Failure to Ensure Timely Behavioral Health Evaluation After Suicidal Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely behavioral psychiatric evaluation and intervention for a resident admitted with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation. The resident experienced multiple episodes of suicidal behavior, including attempts to harm themselves with utensils, and was transferred to the hospital emergency department on several occasions. Despite these incidents, there was no documentation that behavioral psychiatric services evaluated the resident until 13 days after the most recent suicidal episode. Additionally, there was no evidence that the resident's care plan or medications were adjusted in response to these behaviors during this period. The facility's communication process between nursing staff and the behavioral health provider was insufficient, as the nurse practitioner was unaware of the specific suicidal behaviors and attempts involving utensils, despite initialing the behavioral log entries. The nurse practitioner stated that had she been informed of the previous suicidal behaviors, she would have adjusted the resident's plan of care and/or medications earlier. The Director of Nursing was also unaware that the nurse practitioner had not been fully informed of the resident's suicidal behaviors.
Failure to Include Health Care Agent in Care Planning
Penalty
Summary
The facility failed to ensure the participation of a resident's Health Care Agent (HCA) in the development and implementation of the resident's person-centered care plan. The resident, who was admitted in June 2024 and diagnosed with schizoaffective disorder, anxiety disorder, and bipolar disorder, had their Health Care Proxy invoked due to moderate dementia, as determined by their physician in October 2024. Despite this, the facility did not invite the HCA to the care plan meeting held in December 2024, as evidenced by the blank sections on the Care Plan Meeting Invitation and the Interdisciplinary Care Plan Meeting Form, which indicated no invitation was sent or declined, and no attendance was recorded. Interviews with facility staff revealed that the Social Worker was unaware of the invocation of the Health Care Proxy until the day of the survey. The facility's policy requires that care plans be developed with input from the resident and/or their representative, and be evaluated and revised quarterly. However, the lack of documentation and communication with the HCA led to their exclusion from the care planning process, contrary to the facility's policy and expectations set by the Administrator.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident had the right to make healthcare decisions by not obtaining written consent and providing education on the risks and benefits of psychotropic medications before administration. Specifically, for Resident #43, who was admitted with diagnoses including Psychotic Disorder with Hallucinations, generalized Anxiety Disorder, major Depressive Disorder, and Schizophrenia, the facility did not obtain informed written consent for the administration of Risperidone and Sertraline. The resident had moderately impaired cognition but was considered self-responsible and capable of making their own medical decisions. Despite the facility's policy requiring informed consent before administering psychotropic medications, the clinical record showed no evidence of such consent being obtained before the medications were administered from October to December 2023. Interviews with nursing staff and the Director of Nurses confirmed that the responsibility for obtaining consent lay with the nurse completing the admission paperwork. However, the consent forms were only signed by the resident on December 22, 2023, after the surveyor's inquiry, indicating a lapse in following the facility's policy and ensuring the resident's right to make informed healthcare decisions.
Failure to Include Resident in Care Planning Process
Penalty
Summary
The facility failed to include a resident in the care planning process as required. Specifically, the facility staff did not provide evidence of a care plan meeting for a resident who was admitted in October 2023. The resident, who had moderately impaired cognition with a BIMS score of 10 out of 15 and no invoked Health Care Proxy, reported not participating in or being invited to any care plan meetings since admission. The medical record review confirmed the absence of a care plan meeting following the resident's admission and the comprehensive MDS assessment on October 9, 2023. Interviews with the social worker revealed that there was no sign-in sheet or progress note indicating that a care plan meeting had been held for the resident. The social worker admitted that the resident was not invited to any care plan meetings and that no such meetings were held with the interdisciplinary team since the resident's admission. This failure to hold a care plan meeting was contrary to the requirements following the MDS assessment.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement a care plan for a resident with Multiple Sclerosis and muscle weakness, specifically neglecting to apply a left palm guard as ordered for contracture prevention, skin breakdown prevention, and to increase range of motion. The resident's care plan and physician's orders clearly indicated the need for the palm guard to be applied during morning care and removed during evening care. However, observations on multiple occasions revealed that the resident was not wearing the palm guard, and staff interviews confirmed a lack of awareness and adherence to the care plan requirements. The resident expressed concern about the lack of use of the palm guard, noting that their left hand was curling back up, indicating a regression in their condition. Staff members, including a CNA and a nurse, were either unaware of the palm guard requirement or could not recall the last time it was used. The nurse was unable to locate the palm guard in the resident's room and had to contact the rehabilitation department to obtain a new one, highlighting a significant lapse in the continuity of care and adherence to the prescribed treatment plan.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident was weighed weekly as ordered by the physician and recommended by the registered dietitian (RD) following hospitalization and Jejunostomy tube (J-tube) placement. This failure resulted in the delayed identification of a significant weight loss for the resident. The facility's policy required weekly weights for newly admitted residents with a new feeding tube and those with a physician's order for weekly weights. However, the resident's weights were not documented on the specified dates in October and November, as required by the physician's orders and facility policy. The resident, who was admitted in October 2023, had diagnoses including artificial openings of the gastrointestinal tract, dysphagia, and moderate protein-calorie malnutrition. The resident's history and physical indicated poor intake by mouth, failed speech-language pathology evaluations, and the need for a J-tube for enteral nutrition. The RD recommended weekly weights for four weeks, followed by monthly weights. Despite these recommendations, the resident's weights were not recorded on the specified dates, leading to a significant weight loss of 27.4 pounds from October to November. Interviews with the RD revealed that she was unaware that the resident had not been weighed as ordered until she ran the weight report for November. The RD emphasized the importance of regular weight monitoring for calculating nutritional and hydration needs for tube feeding. The lack of documented weights prevented timely identification and intervention for the resident's significant weight loss, highlighting a failure in adhering to the facility's weight monitoring policy and physician's orders.
Failure to Ensure Proper Management of Emergency Medication Kits
Penalty
Summary
The facility failed to ensure that pharmaceutical services were available to meet the needs of each resident. Specifically, the facility did not re-order and replace emergency medication kits (E-Kits) after they were opened, nor did they complete the required documentation for medications removed from the E-Kits. During an observation, several E-Kits, including an IV Kit, a Super Kit, a Coumadin Kit, an Anaphylactic Kit, and an Insulin Kit, were found opened without proper documentation indicating what medications were removed, for which resident, and by which nurse. Additionally, there was no evidence that the forms were faxed to the pharmacy to reorder the kits. Nurse #2 confirmed that the emergency kits on the First Floor [NAME] Wing were the only emergency medication kits in the facility and contained medications not available on other units. The nurse also acknowledged that the required forms were not completed and faxed to the pharmacy, and the facility staff could not provide a policy for managing the E-Kits when requested by the surveyor. This lack of documentation and reordering process led to a failure in ensuring that pharmaceutical services met the needs of the residents.
Failure to Secure Medications
Penalty
Summary
The facility failed to store medications in a safe and secure manner as required. Specifically, the staff did not secure the medication Escitalopram, a psychotropic medication used to treat depression, after it was delivered from the pharmacy. On 12/21/2023 at 9:17 A.M., the surveyor observed two blister pack medication cards containing thirty tablets of Escitalopram laying unsecured on a desk behind the nurses' station on the East Wing. During an interview, the Unit Manager stated that the medication had been delivered at 4:00 A.M. and belonged to a resident who had moved to a different nursing unit. The Unit Manager acknowledged that it was the nurse's responsibility to take the medication to the correct unit and that it was unsafe to leave the medication out in the open where any resident or visitor could access it. The Unit Manager admitted that the medication should have been locked in the medication room until it could be transferred to the appropriate unit.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. For one resident with Multiple Sclerosis and muscle weakness, the facility staff erroneously documented the application of a left palm guard, which had been misplaced and was not being used by the resident. Despite physician orders and care plans indicating the need for the palm guard to prevent skin breakdown and contracture, observations and interviews revealed that the resident had not used the device for approximately one month. Staff members, including a CNA and a nurse, were unaware of the device's status and admitted to incorrect documentation in the Treatment Administration Record (TAR). For another resident with Mild Neurocognitive Disorder, End Stage Renal Disease, and Diabetes Mellitus Type II, the facility failed to maintain accurate records related to Advanced Directive planning. The resident's clinical record contained conflicting documentation regarding their code status, with some notes indicating Full Code and others indicating Do Not Resuscitate (DNR)/Do Not Intubate (DNI). The Medical Orders for Life Sustaining Treatment (MOLST) form was incomplete and not signed by the resident's Health Care Proxy (HCP), leading to confusion about the resident's resuscitation status. The Unit Manager confirmed the discrepancies and the lack of a completed MOLST form, which should have been reviewed and signed by the HCP. These documentation failures highlight significant lapses in the facility's adherence to its policies and procedures for both splint/orthotic device management and advanced directive planning. The inaccuracies in the residents' records could potentially impact the quality of care and the residents' health outcomes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
