Mayflower Place Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Yarmouth, Massachusetts.
- Location
- 579 Buck Island Road, West Yarmouth, Massachusetts 02673
- CMS Provider Number
- 225374
- Inspections on file
- 19
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Mayflower Place Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to properly label, date, and store food products in two nourishment kitchenettes, as observed by a surveyor. Items such as nectar thick juices and a bologna sandwich were either past their discard dates or lacked labeling, contrary to facility policy. Interviews with Food Service Directors revealed that dietary staff were responsible for these tasks, but the procedures were not followed, potentially risking foodborne illness.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, with improper testing procedures and inadequate PPE usage. Staff did not follow correct nasal swab procedures, lacked documentation for testing results, and were not required to wait for test results before starting shifts. Additionally, staff entered COVID-19 positive residents' rooms without required N95 respirators and eye protection, and signage was inaccurate, leading to confusion about necessary precautions.
A resident at high risk for falls experienced nine falls over six months, resulting in injuries and hospitalization, due to the facility's failure to consistently implement fall prevention measures. Observations showed the resident's call light was often out of reach, and purposeful rounding sheets were incomplete. Staff interviews revealed a lack of understanding and inconsistent implementation of the rounding program, leading to inadequate oversight and repeated falls.
The facility failed to implement its antibiotic stewardship program due to incomplete surveillance line listing reports. The policy requires documentation of antibiotic usage and outcomes, but reviews from June to August 2024 showed missing documentation of infection symptoms and onset dates, preventing verification of antibiotic initiation criteria. The Infection Preventionist acknowledged the lack of necessary documentation to ensure appropriate antibiotic prescribing and limit use, highlighting the need for improvement.
Two residents experienced uncomfortable room temperatures due to malfunctioning air conditioning units and poor communication among staff. One resident, who was cognitively intact, had a stuck AC valve, while another with severe cognitive impairment had a thermostat set at 90°F. Despite complaints, maintenance was not informed until surveyor intervention, revealing a breakdown in communication and failure to enter requests into the TELS system.
A resident reported being pushed roughly by a CNA while being assisted onto a bedpan, but the facility failed to complete the investigation and document the resolution of the grievance. The resident, who was cognitively intact and had a hip replacement, was not informed of the outcome, and the Director of Social Services admitted the investigation was incomplete.
A resident reported being roughly handled by a CNA, causing pain, but the facility failed to complete the investigation or report the incident to the state as required. The grievance form was incomplete, and the investigation did not adhere to the facility's abuse policy.
A resident reported being roughly handled by a CNA, causing pain, but the LTC facility failed to report the abuse allegation to the state agency within the required timeframe. The resident, who was cognitively intact, informed staff, but the grievance form lacked necessary documentation, and the incident was not recorded in the HCFRS.
A resident reported being roughly handled by a CNA, but the facility failed to conduct a thorough investigation as required by its abuse policy. The investigation lacked interviews with all relevant parties and did not provide a resolution to the grievance. Key documentation was incomplete, and the resident did not receive updates on the complaint's outcome.
A facility failed to develop and implement individualized care plans for a resident with multiple diagnoses, including heart failure and anxiety. Despite the comprehensive MDS assessment identifying several care areas needing attention, no care plans were documented in the resident's records. An MDS Nurse confirmed the absence of these plans, acknowledging they should have been developed following the MDS assessment.
The facility failed to follow physician orders and ensure timely diagnostic testing for two residents. One resident's lab tests were delayed by six weeks, while another resident's urine sample for a UTI was not collected for five days. The delays were acknowledged by the facility's staff, including the DON, and did not meet the expected standards of practice.
A facility failed to provide consistent Foley catheter care for a resident, leading to a deficiency. The resident, who had frequent UTIs and a history of catheter-related issues, did not have documented orders for catheter care. Observations showed urine with sediment, and staff interviews revealed inconsistent documentation and uncertainty about care procedures. The DON confirmed the lack of adherence to the facility's policy, contributing to the deficiency.
The facility failed to coordinate hospice services for three residents, resulting in incomplete medical records and lack of continuity of care. One resident's hospice binder lacked current certification and documentation of visits, while another's was missing a recertification statement and service schedule. A third resident's hospice service schedule was not provided, and the DON's expectations for documentation were unmet.
A facility failed to ensure accurate MDS assessments for a resident with major depressive disorder and chronic congestive heart failure. The MDS assessments incorrectly indicated the resident received Hospice services, despite no supporting documentation or physician's orders. An MDS nurse confirmed the error during an interview.
A resident at high risk for falls, with a care plan requiring a floor mat for safety, fell and was injured because the mat was not in place. Despite being agitated and restless, staff did not follow the care plan, leading to the incident. The DON confirmed the mat was a required safety intervention.
Improper Food Storage and Labeling in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the labeling, dating, and storage of food products in two nourishment kitchenettes. Observations by the surveyor revealed multiple instances of improperly labeled or unlabeled food items, including nectar thick lemon water, orange juice, cranberry juice, and apple juice, as well as a bologna and cheese sandwich and a can of Wild Cherry Pepsi. These items were either past their manufacturer-recommended discard dates or lacked any labeling to indicate the resident's name and the date of storage, contrary to the facility's policy. Interviews with the Food Service Directors (FSD) indicated that dietary staff were responsible for stocking and cleaning the nourishment kitchenettes, including the removal of expired products. FSD #1 confirmed that all items should be labeled with a resident's name and date and that items brought in by visitors should be discarded within 48 hours. Despite these protocols, the surveyor's findings highlighted a failure in the implementation of these procedures, potentially exposing residents to the risk of foodborne illness.
Inadequate Infection Control and Testing Procedures During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by improper testing procedures and inadequate use of personal protective equipment (PPE). The facility did not ensure that staff members conducted COVID-19 testing in accordance with the Massachusetts Department of Public Health (DPH) guidelines and the manufacturer's instructions for the BinaxNOW antigen test. Specifically, staff members were observed not following the correct nasal swab procedure, and there was a lack of documentation for testing results. Additionally, staff were not required to wait for test results before starting their shifts, and there was no oversight to ensure compliance with testing protocols. The facility also failed to implement appropriate PPE usage for staff caring for COVID-19 positive residents. Observations revealed that staff entered rooms of COVID-19 positive residents without wearing the required N95 respirators and eye protection, despite the availability of PPE outside the rooms. The signage outside resident rooms was inaccurate, leading to confusion among staff about the necessary precautions. This resulted in staff not adhering to the required infection control measures, such as wearing full PPE when entering rooms of COVID-19 positive residents. Furthermore, the facility's documentation and communication regarding testing and PPE protocols were inadequate. The Infection Preventionist admitted to the lack of documentation for staff testing, both at home and in the facility, and acknowledged the confusion among staff regarding PPE requirements. The facility's policies and procedures were not effectively communicated or enforced, contributing to the deficiencies observed during the survey.
Inadequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to consistently implement approaches to prevent falls and provide adequate oversight for a resident who was considered a fall risk. This resident experienced nine falls over a six-month period, resulting in three injuries, including one hospitalization. The facility's policy on incidents and falls, as well as purposeful rounding, was not effectively followed, leading to repeated falls and injuries for the resident. The resident, admitted in September 2023, had multiple diagnoses including cerebrovascular disease, ataxia, polyneuropathy, and restlessness. The resident's Minimum Data Set assessment indicated moderately impaired cognition and a high risk for falls. Despite this, the facility did not consistently implement interventions such as ensuring the call light was within reach, conducting purposeful rounding, and maintaining fall mats on both sides of the bed. Observations revealed that the resident's call light was often out of reach, and the purposeful rounding sheets were incomplete or missing. Interviews with staff indicated a lack of understanding and inconsistent implementation of the purposeful rounding program. The facility's process for investigating falls and updating care plans with new interventions was not effectively executed. Duplicate interventions were noted, and some falls lacked proper investigation and documentation. The Unit Manager and Director of Nursing acknowledged the deficiencies in implementing fall prevention measures and the need for improvement in the process.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by incomplete surveillance line listing reports. The facility's policy on antibiotic stewardship, revised in December 2016, requires the collection and documentation of antibiotic usage and outcome data using a surveillance tracking form. This data is intended to guide decisions for improving antibiotic prescribing practices. However, a review of the facility's surveillance line listings from June 2024 to August 2024 revealed a lack of documentation regarding signs and symptoms of infection for all residents listed, as well as the date of onset. This omission made it impossible to verify whether the minimum criteria for initiating antibiotics were met. Additionally, the line listings did not include the dates when pathogens were identified. During an interview, the Infection Preventionist (IP) acknowledged the absence of symptom documentation on the facility's monthly tracking tools, which is necessary to determine if residents met the clinical criteria for antibiotic initiation. The IP explained that the facility uses the Loeb evidence-based surveillance criteria to define infections, including the type of bacteria, treatment, duration, and whether the infection is facility-acquired. However, she admitted that there was no additional documentation to demonstrate that residents met the criteria for antibiotic stewardship. The IP emphasized that the purpose of the antibiotic stewardship program is to ensure appropriate antibiotic prescribing, limit antibiotic use, and prevent multidrug-resistant organisms (MDROs), indicating that the providers had more work to do in this area.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, leading to a deficiency in providing a safe and comfortable environment. Resident #18, who was cognitively intact and had multiple diagnoses including COVID-19, experienced a very warm and humid room due to a malfunctioning air conditioning unit and a window that would not close properly. Despite the resident's complaints and the room's uncomfortable conditions, maintenance staff were not informed of the issue until the surveyor's intervention. The maintenance staff later discovered that the air conditioning unit's temperature valve was stuck, which was subsequently fixed. Resident #19, who had severe cognitive impairment and was also diagnosed with COVID-19, was found in a hot and humid room with the thermostat set at 90 degrees Fahrenheit. The resident expressed discomfort and thirst due to the heat, and despite previous complaints, the issue was not addressed until the surveyor's visit. Maintenance staff later adjusted the thermostat, which resolved the temperature issue. The lack of communication and failure to enter maintenance requests into the TELS system contributed to the delay in addressing the residents' discomfort. Interviews with staff revealed that there was a breakdown in communication regarding the hot room temperatures. Nurse #6 and the Unit Manager were not aware of the issues until informed by the surveyor, and the Maintenance Director confirmed that no work orders were entered into the TELS system for the hot room temperatures. The Director of Nursing acknowledged that the process for entering work requests was not followed, leading to the deficiency in maintaining a comfortable environment for the residents.
Failure to Resolve Grievance of Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure a resolution for a grievance involving an allegation of physical abuse by a Certified Nursing Assistant (CNA) towards a resident. The grievance was filed by a resident who reported that the CNA pushed them roughly while assisting with a bedpan. The facility's grievance policy requires that such allegations be investigated and documented, including steps taken, findings, and any corrective actions. However, the grievance form was incomplete, lacking documentation of whether the grievance was confirmed, the recommended corrective action, and whether the resident was notified of the outcome. The resident involved was admitted to the facility with a diagnosis of left hip hemiarthroplasty and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite reporting the incident to a nurse and the Social Worker, the resident was not updated on the outcome of their complaint. The Director of Social Services, responsible for overseeing the grievance process, acknowledged that the investigation was incomplete and not properly followed through.
Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation and reporting of an allegation of physical abuse involving a resident. The resident, who was cognitively intact, reported that a CNA had roughly handled them while assisting with a bedpan, causing pain. The resident informed both a nurse and the Social Worker about the incident, but no follow-up or resolution was communicated to the resident. The facility's grievance form was incomplete, lacking confirmation of the grievance, recommended corrective actions, and signatures. The Director of Social Services acknowledged that the investigation was not completed as required, and the Director of Nursing confirmed that the investigation was incomplete and not conducted according to the facility's abuse policy. Additionally, the allegation was not reported to the state agency as mandated by state and federal regulations. This oversight indicates a failure to adhere to the facility's established protocols for handling abuse allegations.
Failure to Timely Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report an allegation of physical abuse by a Certified Nursing Assistant (CNA) to the state agency in a timely manner, as required by their policy. The incident involved a resident who was cognitively intact and had been admitted with a diagnosis of left hip hemiarthroplasty. The resident reported that a CNA had pushed them roughly while assisting with a bedpan, causing pain. The resident informed a nurse the night of the incident and the Social Worker the following day, but no updates were provided to the resident regarding the outcome of their complaint. The facility's policy mandates that allegations of abuse be reported to the state agency within two hours if they involve serious bodily injury. However, a review of the Health Care Facility Reporting System (HCFRS) showed no record of the incident being reported. The Director of Nursing acknowledged that the grievance was an allegation of abuse and that the investigation was incomplete. The grievance form lacked documentation of confirmation, recommended corrective actions, resolution, and administrator review, indicating a failure in the facility's reporting and documentation process.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who reported being roughly handled by a CNA while being assisted onto a bedpan. The resident, who was cognitively intact, reported the incident to a nurse and the Social Worker, but did not receive any updates on the outcome of the complaint. The facility's policy requires a comprehensive investigation of all abuse allegations, including interviews with relevant individuals and a review of the resident's medical record, but these steps were not fully completed. The investigation documentation was incomplete, lacking interviews with all relevant parties and a resolution to the grievance. Key sections of the Grievance/Concern form, such as confirmation of the grievance, recommended corrective action, and notification to the resident, were left blank. Interviews with the Director of Social Services and the DON confirmed that the investigation was not conducted thoroughly, as required by the facility's abuse policy.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident, which is a requirement according to their policy. The resident, admitted in July 2024, had multiple diagnoses including heart failure, urinary retention, anxiety, glaucoma, and difficulty walking. The comprehensive Minimum Data Set (MDS) assessment identified several care areas that needed attention, such as cognitive loss/dementia, visual function, communication, ADL functioning/rehabilitation potential, urinary incontinence, behavioral symptoms, falls, nutritional status, and pressure ulcers. Despite these identified needs, the facility did not have any comprehensive care plans documented in the resident's medical records, both paper and electronic. During an interview, the MDS Nurse confirmed the absence of these care plans, acknowledging that they should have been developed following the completion of the comprehensive MDS and the triggering of care areas. This oversight indicates a failure to adhere to the facility's policy, which mandates the creation of a comprehensive care plan within 21 days of admission.
Failure to Follow Physician Orders and Timely Diagnostic Testing
Penalty
Summary
The facility failed to follow physician's orders and ensure timely completion of diagnostic tests for two residents, leading to deficiencies in care. Resident #20, who had diagnoses including hypertension, chronic obstructive pulmonary disease, and anemia, was prescribed a complete metabolic panel (CMP), complete blood count (CBC), and thyroid stimulating hormone (TSH) tests on May 20, 2024. Despite the physician's order and the nurse's notation, these tests were not completed until July 3, 2024, six weeks after the initial order. The Unit Manager confirmed the absence of lab results for May and acknowledged the error, while the physician expressed that the delay was unacceptable and did not meet the standard of practice. Resident #13, diagnosed with dementia, hypertension, and a urinary tract infection (UTI), was ordered a urinalysis (U/A) culture and sensitivity (C&S) test on August 2, 2024, following a fall from bed. The order included the option to use a straight catheter if necessary. However, by August 7, 2024, the urine sample had not been collected, and there was no documentation of any attempts or issues in obtaining the sample. The physician expected the sample to be collected by the next day, and the family member expressed dissatisfaction with the delay, considering it excessive given the resident's history of frequent UTIs. The Director of Nurses acknowledged the delays in both cases, stating that the expected timeframe for obtaining lab results and urine samples was not met. The facility's policies and the Massachusetts Board of Registration in Nursing Advisory Ruling emphasize the responsibility of licensed nurses to ensure timely implementation of physician orders, which was not adhered to in these instances.
Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling catheter for a resident, leading to a deficiency in catheter care. The facility's policy required catheter care to be performed at least twice daily, with specific procedures to minimize the risk of catheter-associated urinary tract infections. However, the medical records for the resident did not indicate consistent documentation of Foley catheter care, and there was no order for such care in place. Observations by the surveyor revealed that the resident's catheter was draining urine with sediment, and the resident reported frequent urinary tract infections. Interviews with staff, including a nurse and the unit manager, confirmed that Foley catheter care was not being consistently documented or performed according to the facility's policy. The nurse acknowledged that the resident had frequent urinary tract infections and periods of inflammation at the catheter insertion site. The unit manager admitted uncertainty about the required care for Foley catheters and where it should be documented, further indicating a lack of adherence to the facility's policy. The Director of Nursing confirmed that the resident was at higher risk for complications due to the condition of the catheter site and the resident's legal blindness. Despite the facility's policy and the resident's care plan, catheter care interventions were not consistently implemented. The lack of a documented order set for Foley catheter care and the absence of consistent documentation and monitoring contributed to the deficiency identified by the surveyor.
Deficiencies in Hospice Service Coordination and Documentation
Penalty
Summary
The facility failed to coordinate hospice services effectively for three residents, leading to deficiencies in maintaining complete medical records and ensuring continuity of care. For one resident, the facility did not provide ongoing documentation or maintain a complete medical record of hospice services, which hindered effective communication for continuity of care. The hospice binder lacked a current hospice certification and plan of care, as well as documentation of visits by nursing, home health aides, or social services. The unit manager was unable to locate the hospice schedule, and a nurse was unaware of the required information for the hospice binder. Another resident's hospice binder was missing a current recertification statement and a schedule of hospice services, which are necessary for maintaining continuity of care. The unit manager acknowledged that the hospice record was incomplete and that the hospice schedule was not posted as it should be. The social worker, responsible for checking the binders weekly, confirmed that the recertification period was not current, indicating a lapse in updating the necessary documentation. For the third resident, the facility did not provide an official schedule of hospice services, and the nurse was unaware of the timing of these services. The Director of Nursing expected the most recent hospice certification and all related documentation to be included in the resident's record, along with a physician's order for hospice admission. However, these expectations were not met, as the hospice provider schedule was not posted on the unit or in the resident's record.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. The resident was admitted in January 2023 with diagnoses including major depressive disorder and chronic congestive heart failure. MDS assessments dated March 13, 2024, and June 12, 2024, incorrectly indicated that the resident received Hospice services. However, a review of both paper and electronic medical records showed no physician's order, documentation, or care plans to support that the resident received Hospice services. During an interview, MDS Nurse #2 confirmed that the resident did not receive Hospice services during those assessment dates and acknowledged that the MDS entries were made in error.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement and follow safety interventions for a resident assessed as high risk for falls. The resident, who had multiple diagnoses including dementia with anxiety and psychotic disorder with delusions, was admitted in January 2024. The comprehensive care plan for this resident included the use of a floor mat next to the bed as a safety measure. However, the care plan did not specify the exact placement of the mat, leading to confusion among staff. On May 14, 2024, the resident fell out of bed and sustained a skin tear to the left side of the head because the floor mat was not in place. Interviews with staff revealed that on the day of the incident, the resident was agitated and restless. Despite the care plan's instructions, the floor mat was not placed on the floor next to the bed, as confirmed by both the nurse and CNA involved in the resident's care. The Director of Nurses acknowledged that the floor mat was part of the resident's care plan and should have been in place as a fall safety intervention. The failure to ensure the mat was consistently used as per the care plan led to the resident's fall and subsequent injury.
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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