Meadow Green Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waltham, Massachusetts.
- Location
- 45 Woburn Street, Waltham, Massachusetts 02453
- CMS Provider Number
- 225440
- Inspections on file
- 16
- Latest survey
- March 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Meadow Green Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to inform residents of services available and charges for those not covered under Medicare/Medicaid, as they did not provide SNF/ABNs to two residents. A social worker mentioned she had never issued an ABN, and the administrator confirmed the facility was not issuing them, although they should be.
The facility failed to provide proper respiratory care for four residents, including missing physician's orders for oxygen, incorrect oxygen flow rates, and improper management of oxygen and nebulizer equipment. Observations revealed issues such as unlabeled and improperly stored tubing and masks, and non-compliance with weekly change schedules. The DON confirmed the need for adherence to professional standards in respiratory care.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for three residents with indwelling devices, as there was no signage or PPE available outside their rooms. Additionally, staff did not adhere to proper glove use and hand hygiene protocols, wearing gloves in hallways and failing to sanitize hands after glove removal. Interviews with the nursing leadership confirmed these lapses in infection control practices.
The facility failed to maintain a dignified environment for two residents. One resident with dementia was referred to by their level of assistance as a 'feeder' by a CNA, contrary to facility policy. Another resident with moderate cognitive impairment was assisted with a meal by a hospice staff member who stood while feeding them, which is against the facility's practice of assisting residents while seated at eye level. The Director of Nurses confirmed these practices should not occur.
The facility failed to consistently document Advance Directives for two residents, leading to discrepancies in their medical records. One resident had conflicting documentation regarding their code status, while another resident's preferences were not discussed or documented. Staff interviews revealed that the facility's policy requires consistent documentation of advance directives, which was not adhered to in these cases.
The facility failed to implement care plans for three residents, leading to deficiencies in their care. A resident with Picks dementia and PICA was repeatedly given trays with hazardous items, despite care plan instructions. Two other residents, one with dementia and another with dysphagia, were left unsupervised during meals, contrary to their care plans. Staff interviews confirmed these oversights, highlighting a lack of adherence to established care protocols.
A facility failed to obtain daily weights for a resident as ordered by the physician, despite the resident's medical condition requiring close monitoring. The resident was admitted with acute respiratory failure and other conditions, and the physician's orders specified daily weights with specific thresholds for notifying the MD/NP. However, the facility's records did not show daily weights being taken, nor any documentation of refusal or notification to the physician, indicating a lapse in following professional standards of care.
A resident with vision issues was not referred to a retina specialist as recommended by an optometrist, despite multiple evaluations indicating the need for further assessment. The resident, who was cognitively intact and an avid reader, expressed concerns about unclear vision. Facility staff were unaware of the recommendation, and no appointment was scheduled, highlighting a breakdown in communication and follow-up.
A resident with pressure ulcers did not receive necessary treatment as the facility failed to implement the consulting wound physician's recommendations to off-load a wound on the left heel. The resident was observed with heels directly on the mattress, and there was no physician's order for an air mattress, which was in use but not set according to the resident's weight. Facility staff confirmed the lack of necessary orders and care plan adjustments.
A facility failed to maintain professional standards in urinary catheter care for a resident, as the catheter drainage bag was observed resting on the floor, contrary to standard practice. Despite the presence of three nurses, the issue was not addressed. The resident had an indwelling catheter due to urinary retention, and the care plan highlighted the risk of complications. Interviews confirmed that the bag should not contact the floor to prevent infection.
A facility failed to maintain accurate medical records for a resident with chronic conditions requiring oxygen therapy. The resident's oxygen tubing was not replaced as documented in the Treatment Administration Record (TAR), despite physician orders for weekly changes. Observations showed the tubing was labeled with an outdated date, and interviews with staff confirmed the documentation should have been accurate.
A resident with a history of falls and requiring two-person assistance for transfers was injured when a CNA transferred them alone, resulting in a fractured ankle needing surgery. The facility's policy emphasized the need for two-person assistance, which was not followed, leading to the incident.
A facility failed to create a comprehensive care plan for a resident needing two staff members for transfers. Despite policies requiring detailed care plans, the resident's plan lacked specific interventions, goals, or outcomes for their transfer needs. The resident, with a history of falls and arthritis, was assessed as needing maximum assistance, but the care plan did not document this requirement. The DON admitted the care plan was vague and did not reflect the resident's specific needs.
A facility failed to protect seven residents from abuse and neglect by staff. One resident, with diagnoses including legal blindness and anxiety, reported emotional distress after a CNA forced them to take a shower against their will. Family members raised concerns about emotional abuse. Additionally, six residents with incontinence issues, including one with Alzheimer's disease, experienced neglect in timely toileting, leading to soiled clothing and skin issues. The report indicates systemic issues in providing essential incontinence care, resulting in potential discomfort and skin problems for the affected residents.
The facility failed to file and resolve grievances brought to the Resident Council group for four months. Repeated complaints about staff not wearing name badges, long call bell wait times, and menus not matching the food being served were not filed as grievances. Residents expressed frustration, and the Administrator acknowledged the oversight.
The facility failed to ensure medications were properly labeled after opening in three medication carts across three nursing units and did not lock medication carts when unattended on one unit. Multiple medications were found open and undated, and treatment carts were observed unlocked and unattended, indicating lapses in adherence to medication labeling and storage policies.
The facility failed to ensure effective administration, resulting in inadequate staff training, unresolved grievances, and an insufficient QAPI program. Employee records showed missing competencies and training, residents expressed frustration over unresolved issues, and recurring concerns were not addressed through QAPI projects.
The facility's governing body failed to provide oversight and accountability in critical areas, including the grievance process, staff education, quality of care related to abuse, and sustaining a sufficient QAPI program. Residents' grievances were not addressed, staff competencies were not documented, and allegations of abuse were not investigated. Repeated concerns from the Resident Council were also not addressed.
The facility failed to maintain an effective QAPI program, lacking prioritization, benchmarks, and regular data review. Issues such as incomplete dementia training, inaccurate documentation, and recurring resident concerns were not addressed through QAPI projects. The Facility's Owner was unaware of these issues and the current QAPI projects.
The facility failed to develop and implement policies for a systematic approach to determine underlying causes of problems, develop corrective actions, establish performance benchmarks, and monitor the effectiveness of performance improvement activities. The QAPI program lacked regular meetings and documentation, with no records for several months.
The facility failed to ensure staff followed infection control standards, particularly droplet precautions, and lacked documentation for a water management program to prevent the spread of waterborne infections. Observations included staff not wearing appropriate PPE and a CNA assisting a resident with Clostridium Difficile without a protective gown.
The facility failed to report abuse allegations for seven residents within the required two-hour time frame and did not provide timely incontinence care for multiple residents. Incidents of forced showers and neglect in providing incontinence care were not reported promptly, exposing residents to further potential harm.
The facility failed to complete significant change MDS assessments within the required time frame for two residents. One resident was admitted to hospice services, and another experienced a significant decline in condition after a fall, but the necessary assessments were not completed.
The facility failed to follow and develop personalized care plans for six residents, including not ensuring fall mats were in place, lacking cognitive care plans for dementia, not following pressure ulcer care plans, and not addressing contractures and Pica behaviors.
The facility failed to provide necessary assistance with ADLs for 16 residents, leading to multiple deficiencies. Residents requiring feeding assistance, incontinence care, and hygiene support were left unsupervised and neglected, contrary to their care plans. Staff interviews confirmed the lack of adherence to facility policies, resulting in compromised resident care.
The facility failed to ensure that nursing staff received the appropriate competencies and skill sets necessary for resident care. Annual competencies were not completed and documented for four CNAs and four licensed nurses. The facility also lacked a policy and procedure for ensuring nursing staff competency, and the ADON was unable to locate the required documentation or identify who was responsible for oversight.
The facility failed to complete annual performance reviews and provide regular in-service education for CNAs based on these reviews for 4 out of 4 CNA records reviewed. The ADON was unable to locate the performance reviews and did not know who was responsible for their oversight.
The facility failed to maintain accurate medical records and provide proper care for five residents. Issues included conflicting documentation, lack of assistance during meals, failure to follow physician orders for fall mats and pain patches, and not providing prescribed pressure-relieving booties. The DON and other staff acknowledged the inaccuracies and incomplete documentation.
The facility failed to provide the required in-service training for CNAs, including the mandated 12 hours per year and dementia management training. Records for four CNAs showed delays or absence of initial and annual dementia training, and the ADON admitted to not knowing the total training hours due to poor documentation.
The facility failed to obtain consents for psychotropic medications before administering them to two residents with severe cognitive impairment. Both residents received multiple doses of medications without signed consent from their health care proxies, contrary to the facility's policy and expectations.
A resident with moderate cognitive impairment and dependence on staff for functional tasks was found with Voltaren Arthritis Pain gel in their room, which they reported using without a physician's order or an assessment for self-administration. Facility staff confirmed that the resident should not have medications in their nightstand and should not self-administer without proper assessment and orders.
A resident with moderate cognitive impairment and multiple diagnoses was observed on several occasions calling out for help without the call light being within reach. Despite the facility's policy and care plan, the call light was not accessible, and the resident was unable to call for assistance.
The facility failed to secure residents' Protected Health Information (PHI) on two nursing units. Medication carts with open computer screens displaying personal medical information were observed, with nurses either absent or not monitoring the screens. Both nurses and the Corporate Nurse acknowledged the inappropriateness of this practice.
The facility failed to make grievance information available to residents and did not file or resolve grievances for three residents. Multiple complaints about care, including not being fed, poor hygiene, and lost dentures, were not formally addressed. Staff admitted to not using grievance forms and only addressing issues verbally due to time constraints.
A resident with multiple diagnoses was found with blankets and pillows stuffed under the fitted sheet, restricting movement. This setup was not documented as a restraint, and staff failed to follow the facility's restraint policy, which requires assessment, a physician's order, and consent.
A resident reported being forced to take a shower against their will by a CNA, who sprayed water in their face and used excessive shampoo. Despite being notified, the DON failed to investigate or report the abuse allegation within the required timeframe. The incident was reported to HCFRS nine days later, indicating a significant delay.
The facility failed to investigate allegations of abuse and neglect for two residents, leading to deficiencies in care. One resident reported being forced to shower against their will, causing emotional distress, while another resident's daughter reported multiple complaints of neglect without resolution. The facility did not conduct formal investigations or take appropriate actions in response to these allegations.
The facility failed to provide a copy of the transfer/discharge notice upon transfer to the hospital for a resident. The resident, admitted with Covid-19 and heart failure, was discharged to the hospital, but the required notice was not given to the resident or their representative. The DON confirmed the notice could not be located and should have been provided.
The facility failed to complete quarterly care plan meetings for two residents, leading to deficiencies in their care. One resident had not had a care plan meeting for over three months, while another had not had a documented meeting since a significant decline in health. The facility's scheduling and documentation processes were found to be inadequate.
The facility failed to administer lidocaine patches to a resident as per the physician's order, causing discomfort. The MAR did not indicate the patches were administered, and there was no documentation of refusal. Interviews confirmed the patches were not applied, and the facility's medication administration policy was not followed.
The facility failed to provide an activities program that met the interests and supported the well-being of a resident with severe cognitive impairment. The resident expressed boredom and a desire to participate in activities but did not receive a care plan specific to activity preferences, a handheld activities calendar, or engagement in scheduled activities. Staff interviews confirmed the absence of a tracking system for resident participation in activities.
The facility failed to maintain a safe environment for two residents, leading to significant risks of choking and burns. One resident with Pick's disease and aphagia was repeatedly left unsupervised, placing non-edible items in their mouth. Another resident with dysphagia and dementia was inadequately supervised while consuming hot coffee, resulting in spills and potential burn risks.
A resident with dementia and moderate cognitive impairment reported dental pain and had not been seen by a dentist in the past year, despite having a consent form and physician order for dental services. The ADON was unaware of this lapse in care.
The facility failed to provide the correct therapeutic diets for three residents, leading to the serving of inappropriate food textures despite specific dietary orders. The nursing staff and Food Service Director were unaware of the errors, and the lack of supervision during meals was noted as a contributing factor.
The facility failed to ensure proper hospice care coordination and documentation for two residents, including the lack of a signed hospice agreement, missing physician's orders, and inadequate communication and documentation of hospice visits.
The facility failed to implement and maintain an effective training program for all new and existing staff members, as required by the facility assessment. A review of employee records revealed a lack of yearly competencies and mandatory training, including effective communication, resident rights, abuse, neglect, and exploitation. The ADON was unable to locate the competencies and did not know who was responsible for oversight.
The facility failed to provide a bed-hold notice to a resident or their representative upon transfer to the hospital, as required by policy. The resident, admitted with Covid-19 and heart failure, was discharged to the hospital, but the necessary documentation was not given. The DON confirmed the oversight.
Failure to Provide SNF/ABNs to Residents
Penalty
Summary
The facility failed to inform residents of the services available and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the facility did not provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF/ABNs) to two applicable records reviewed. During an interview, a social worker stated she had never issued an ABN before and indicated that the business office was responsible for issuing them. The facility administrator confirmed that the facility was not issuing the ABNs, although they should be.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for four residents. For one resident, the facility did not include a physician's order for oxygen in the medical record and set the oxygen flow rate incorrectly. The resident was observed wearing a nasal cannula with oxygen set at 1.5 liters, while the correct setting should have been 2 liters. The Director of Nurses confirmed that a physician's order should have been in place for safe oxygen administration. Another resident's oxygen tubing was not changed and dated as per the physician's orders. The tubing was observed to be labeled with a date that was not consistent with the weekly change schedule. The Director of Nursing confirmed that the tubing should be changed weekly and stored in a plastic bag when not in use. For two other residents, the facility failed to properly store and label nebulizer tubing and masks. The nebulizer equipment was observed on the residents' nightstands without being labeled or stored in a bag. The Director of Nursing confirmed that nebulizer tubing and masks should be changed weekly, labeled, and stored in a bag when not in use.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBPs) for three residents. Resident #306, who was admitted with acute respiratory failure and a urinary catheter, did not have signage or personal protective equipment (PPE) available outside the room to indicate the need for EBPs. Similarly, Resident #95, with a cholecystostomy tube, and Resident #40, with a nephrostomy tube, also lacked appropriate signage and PPE outside their rooms, indicating a failure to implement necessary precautions to prevent the spread of infections. Additionally, the facility's staff did not adhere to proper glove use and hand hygiene protocols. Observations revealed that staff members wore gloves in the hallways and failed to perform hand hygiene after glove removal, which is against the facility's policy. For instance, a housekeeping staff member was seen using a gloved hand to hold open an elevator door and later failed to sanitize his hands after removing gloves, potentially contaminating surfaces. Interviews with the Corporate Director of Nurses and the Director of Nurses confirmed that the facility's expectations were not met regarding the implementation of EBPs and proper glove use. The Director of Nurses acknowledged that EBPs should be in place for residents with open areas or indwelling devices, and staff should not wear gloves in hallways without performing hand hygiene afterward. These lapses in infection control practices highlight the facility's failure to maintain a safe and sanitary environment for residents.
Failure to Provide a Dignified Environment for Residents
Penalty
Summary
The facility failed to provide a dignified environment for two residents, leading to a deficiency in resident rights. For one resident, who was admitted with dementia and is rarely understood, a Certified Nurse's Assistant (CNA) referred to the resident by their level of assistance, calling them a 'feeder.' This was observed during an interaction in the dining room, where the CNA confirmed the resident had finished eating and used the term 'feeder' to describe them. The Director of Nurses later confirmed that staff should not address residents by their care level needs. Another resident, admitted with adult failure to thrive and moderate cognitive impairment, was assisted with a meal by a hospice staff member who stood while feeding them. This was observed during breakfast, and the CNA acknowledged that staff, including hospice staff, should not assist residents with meals while standing and should not refer to residents by their care needs. The Director of Nurses reiterated that all staff should assist residents while seated at eye level and should not refer to residents based on their level of care.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical records for two residents, leading to a deficiency. Resident #11, who was admitted with severe cognitive impairment and various medical conditions, had a MOLST form indicating Do Not Resuscitate and Do Not Intubate, signed by both the Health Care Proxy and the physician. However, discrepancies were found in the documentation, as the care plan indicated a full code status, conflicting with the MOLST form. Interviews with the Unit Manager and Director of Nurses revealed that advanced directives should be consistently documented across the medical record, including physician's orders, care plans, and MDS assessments. Resident #95, admitted with intact cognition and medical conditions such as sepsis and acute respiratory failure, did not have a documented plan of care regarding advanced directives. The medical record lacked a completed MOLST form, and progress notes failed to indicate any discussion of advanced directives. During an interview, Resident #95 expressed a preference for Do Not Resuscitate status, which had not been communicated or documented by the facility staff. The Unit Manager and Director of Nurses acknowledged that a MOLST form should be completed or attempted for every resident, and any refusal should be documented. The deficiency was identified through a review of facility policies, medical records, and interviews with staff and residents. The facility's policy requires that residents be informed about advance directives upon admission and that any assistance offered or declined be documented. The failure to consistently document and discuss advance directives with residents and their representatives led to a lack of clarity in the residents' medical records, contributing to the deficiency.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for three residents, leading to deficiencies in their care. Resident #56, who has a history of placing non-food items in their mouth due to Picks dementia and PICA, was observed with hazardous items on their food tray multiple times. Despite the care plan specifying that such items should be removed before the tray is given to the resident, observations showed that items like condiment packets, paper products, and plastic lids were repeatedly left within reach. Interviews with staff confirmed that these items should have been removed, but the care plan was not consistently followed. Resident #46, diagnosed with dementia and requiring supervision during meals, was left unsupervised while eating on several occasions. The resident was observed eating alone in their room, not within eyesight of staff, and was noted to be coughing, which increased the risk of aspiration. Despite the care plan and assessments indicating the need for close supervision due to cognitive impairments, the resident was not provided with the necessary oversight during meals. Resident #32, who has Type 2 Diabetes Mellitus, acute kidney failure, and dysphagia, was also not provided with the required supervision during meals. The resident, who experiences a right-hand tremor, was observed eating alone with food spilled on their clothing, indicating a lack of assistance. The care plan specified supervision and monitoring for signs of choking, but staff interviews revealed a misunderstanding of the resident's needs, leading to inadequate support during meals.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for a resident. Specifically, the facility did not obtain daily weights for a resident as indicated in the physician's orders. The resident was admitted with diagnoses including acute respiratory failure with hypoxia and retention of urine. The physician's orders required daily weights if the resident's weight increased by more than 3 pounds in one day or more than 5 pounds in one week, with instructions to call the MD/NP if these thresholds were met. However, the electronic medical record showed that weights were not recorded daily, and there was no documentation of the resident refusing to be weighed or the physician being notified of the lack of daily weights. Interviews with facility staff revealed that daily weights should have been completed at 6:00 A.M. each day as per the physician's orders. The Unit Manager confirmed that the resident did not refuse care, and the Director of Nurses stated that she expected nurses to follow physician's orders as it is the standard of practice. Despite these expectations, the facility's records did not reflect compliance with the physician's orders for daily weights, indicating a failure to meet professional standards of quality care for the resident.
Failure to Refer Resident to Retina Specialist
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision ability. Specifically, the facility did not refer the resident to a retina specialist for further evaluation as recommended by the optometrist. The resident, who was cognitively intact and an avid reader, expressed concerns about needing new lenses due to unclear vision. The optometrist had identified a presumed macular hole and suspected glaucoma, recommending a follow-up with a retina specialist for further evaluation. Despite multiple evaluations by the optometrist over several months, the resident's medical record did not indicate any evaluation by a retina specialist, nor was there an appointment scheduled. The resident's health care proxy was unaware of the need for a retina specialist, and the facility's social worker mentioned that the facility would reach out to the family if the routine optometrist could not meet the resident's needs. However, this did not occur. Interviews with facility staff revealed a breakdown in communication and follow-up. The nurse practitioner and medical doctor were unaware of the optometrist's recommendation for a retina specialist referral. The Director of Nursing acknowledged that the Assistant Director of Nursing, who previously handled ancillary service evaluations, had left the facility, which may have contributed to the oversight. The deficiency was identified after the surveyor brought the concern to the facility's attention.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was admitted with diagnoses including sepsis, type 2 diabetes mellitus, and acute respiratory failure, had two unstageable pressure ulcers upon admission and was at high risk for further skin breakdown. Despite recommendations from the consulting wound physician to off-load the wound on the resident's left heel, the facility did not have a physician's order in place to implement this recommendation. Observations over several days showed the resident lying in bed with heels directly on the mattress, indicating a failure to off-load the wound as recommended. Additionally, the resident was observed using an air mattress set at 240 pounds, although their documented weight was 200.2 pounds. There was no physician's order for the air mattress, nor was it included in the resident's care plan or recommended by the consulting wound physician. Interviews with facility staff, including the Unit Manager and the Director of Nurses, confirmed that the necessary orders and care plan adjustments were not made, which are essential for monitoring and ensuring appropriate settings for the air mattress.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident. Specifically, the urinary catheter drainage bag for a resident was observed resting directly on the floor, which is against the standard practice of keeping the bag elevated to prevent infection. This observation was made twice on the same day, once at 6:57 A.M. and again at 7:17 A.M., even after three nurses entered and exited the resident's room without addressing the issue. The resident involved was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and urinary retention. The resident's care plan, initiated shortly before the observation, indicated the presence of an indwelling urinary catheter and highlighted the risk of complications related to its insertion. Interviews with the Infection Preventionist and the Director of Nurses confirmed that the catheter bag should not be in contact with the floor, as it increases the risk of infection.
Inaccurate Documentation of Oxygen Tubing Replacement
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #21, who was admitted with diagnoses including acute and chronic diastolic heart failure, chronic obstructive pulmonary disease (COPD), and hypertensive heart disease without heart failure. The resident, who had intact cognition, required partial to moderate assistance for daily self-care activities and was on oxygen therapy. According to the physician's orders, the resident's oxygen tubing was to be replaced and dated every Sunday during the night shift. However, observations on February 25, 2025, revealed that the oxygen tubing was labeled with a date of January 27, 2025, indicating it had not been changed as documented. The Treatment Administration Record (TAR) for February 2025 inaccurately indicated that the oxygen tubing was changed on February 2, 9, 16, and 23. Interviews with Nurse #1 and the Director of Nursing confirmed that the documentation should accurately reflect the day the oxygen tubing was changed. The Director of Nursing stated that any resident on oxygen should have the tubing changed weekly, and she expected this to be accurately documented in the medical record. This discrepancy between the documented and actual practice led to the deficiency noted in the report.
Inadequate Staff Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide the necessary level of staff assistance for a resident who required the assistance of two staff members for all transfers. On 09/28/24, a Certified Nurse Aide (CNA) transferred the resident without assistance from another staff member, resulting in the resident sustaining a fractured right ankle that required surgical intervention. The facility's policy on safe lifting and movement of residents, dated 08/01/23, emphasized the importance of incorporating resident safety, dignity, comfort, and medical condition into decisions regarding safe lifting and movement. The resident, admitted in September 2023, had a history of falls, dementia, rheumatoid arthritis, and osteoarthritis, and was assessed to require maximum assistance of two staff for transfers. Despite this, the CNA transferred the resident alone, leading to the injury. The incident was confirmed through interviews with facility staff and a review of the resident's care plan and medical records, which consistently indicated the need for two-person assistance for transfers. The CNA did not respond to requests for an interview, but a signed statement confirmed the solo transfer on 09/28/24.
Failure to Develop Comprehensive Care Plan for Resident Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required assistance from two staff members for transfers. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan with measurable objectives and timetables, the care plan for the resident did not include specific interventions, goals, or outcomes related to their transfer status. The resident, admitted in September 2023, had a history of falls, dementia, rheumatoid arthritis, and osteoarthritis, and was assessed as needing maximum assistance from two staff members for transfers. The deficiency was identified through a review of various documents, including the resident's hospital physical therapy discharge assessment, post-admission care plan meeting note, certified nurse aide activities of daily living flowsheet, annual minimum data set assessment, and physical therapy evaluation. These documents consistently indicated the resident's dependency on staff for transfers. However, the care plan lacked documentation supporting the need for two staff members for transfers. During an interview, the Director of Nurses acknowledged that the care plan's intervention for transfers was vague and did not reflect the specific care the resident required.
Resident Abuse and Neglect in Incontinence Care Identified
Penalty
Summary
The facility failed to protect seven residents from abuse and neglect by staff, as identified in the report. Resident #5, who had diagnoses including legal blindness, cerebral infarction, anxiety, and depression, alleged that a Certified Nursing Assistant (CNA) forced them to take a shower against their will, causing emotional distress. Despite Resident #5's refusal, the CNA proceeded to shower them, leading to fear and ongoing refusal of showers. Family members expressed concern and reported the incident to facility management, citing emotional abuse and its impact on Resident #5's well-being. Similarly, Residents #100, #19, #108, #26, #62, and #90 were neglected in terms of incontinence care. For example, Resident #100, diagnosed with Alzheimer's disease, was observed with urine leakage and soiled clothing due to lack of timely toileting. The facility's failure to provide necessary incontinence care resulted in skin issues for Resident #100. The report highlighted instances where residents were left in soiled conditions for extended periods, indicating a systemic issue in providing essential care to incontinent residents, leading to potential discomfort and skin problems.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to file and resolve grievances brought to the Resident Council group for four months. The policy titled 'Grievances' dated 8/1/23, outlines that the facility will assist residents, their representatives, family members, or resident advocates in filing a grievance/concern form when concerns are expressed. The policy also states that grievances may be reviewed in writing, orally, or anonymously, and the same process will be followed regardless of the method in which a grievance/concern is conveyed. However, review of the Resident Council minutes for October 2023, November 2023, December 2023, February 2024, and March 2024 indicated repeated complaints about staff not wearing name badges, long call bell wait times, and menus not matching the food being served. These issues were not filed as grievances in the grievance log for 2023 and 2024. During an interview, nine out of nine participating residents expressed frustration, stating that they complain about the same issues month after month and feel the facility does not respond to grievances brought up in the group meeting. The Administrator, who has been overseeing the grievance process, acknowledged that he was unaware that the repeated concerns from the resident group were not addressed and confirmed that grievances should have been made for all those concerns. The failure to address these repeated concerns led to the deficiency identified in the report.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled after opening in three of three medication carts observed on three of three nursing units. Specifically, multiple bottles of medications and supplements, including Liquacel protein supplement, UTI-stat, Anoro Ellipta inhaler, Carboxymethylcellulose Sodium ophthalmic drops, artificial tears, Erythromycin antibiotic eye ointment, and Latanoprost eye drops, were found open and without dates. Nurses interviewed during the survey were either unable to answer questions about the undated medications or acknowledged that medications should be dated when opened, indicating a lapse in adherence to the facility's medication labeling policy. Additionally, the facility failed to ensure that medication carts were locked when unattended on one of three nursing units. The surveyor observed treatment carts on the Brooknoll unit unlocked and without a nurse within view on multiple occasions. Interviews with nurses confirmed that the treatment carts should always be locked when not in use, yet the surveyor was able to access an unlocked and unattended medication cart, highlighting a significant security lapse in medication storage practices.
Deficiencies in Staff Training, Grievance Handling, and QAPI Program
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled the effective use of resources to attain the highest practicable well-being of each resident. Specifically, the administration did not provide adequate education and training to staff, failed to complete the grievance procedure, and did not sustain a sufficient Quality Assurance Performance Improvement (QAPI) program. Review of employee records revealed that competencies and required training, including dementia training, were not completed as per the facility's assessment. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed the lack of oversight and documentation regarding staff competencies and training hours. The facility also failed to address grievances effectively. During a resident group meeting, all participating residents expressed frustration over recurring issues that were not being resolved. The surveyor found no grievance forms available on any of the resident units, and the grievance log indicated no grievances had been filed since October 2023. Interviews with the Administrator and Unit Manager revealed that the grievance process had not been followed, and concerns were not formally documented or addressed. Additionally, the facility did not utilize its QAPI program to address recurring concerns raised by residents. Review of Resident Council minutes from October 2023 to March 2024 showed repeated complaints about staff not wearing name badges, long call wait times, and discrepancies between menus and the food served. The Administrator admitted that these concerns should have been made into QAPI projects but were not. The Facility's Owner was also unaware of the recurring issues and the current QAPI projects, indicating a lack of communication and oversight.
Governing Body Fails to Provide Oversight and Accountability
Penalty
Summary
The facility failed to ensure that the governing body provided oversight and accountability in several critical areas, including the grievance process, staff education and competencies, quality of care related to abuse, and sustaining a sufficient QAPI program during leadership transitions. The governing body did not have a clear plan to ensure the facility could safely provide services to meet the residents' needs and implement an effective QAPI program. The Facility Assessment did not list the members of the Governing Body, and the Facility's Owner admitted that the responsibility mainly fell on him due to his parents' advanced age. Nine residents reported that their grievances were not being addressed, and they were unaware of how to file a formal grievance. The grievance log showed no grievances had been filed since October 2023. The Administrator was unaware of this lapse, and Unit Manager #1 admitted to not using grievance forms for a while. The Facility's Owner was also unaware of the lack of grievance filings and expected the grievance procedure to be completed per facility policy. The facility also failed to ensure staff completed required competencies and education. Employee records for CNAs and licensed nurses lacked documentation of yearly competencies and dementia training. The ADON was unable to locate competencies for any of the reviewed employee records and did not know who was responsible for oversight. Additionally, the facility failed to investigate allegations of abuse for two residents. Resident #5 reported being forced to take a shower against their will, and Resident #47's daughter reported neglect, but no investigations were conducted. The Facility's Owner was not kept up to date with concerns about abuse. Repeated concerns from the Resident Council about staff not wearing name badges, long call wait times, and menu discrepancies were not addressed through QAPI projects, indicating a lack of effective governance and leadership.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program. The QAPI committee did not prioritize activities, develop benchmarks, or establish processes for evaluating outcomes. The facility's QAPI program lacked action plans, performance tracking, and regular data review. Additionally, the facility did not meet regularly to review and analyze data, with no documentation of meetings for several months in 2023. The Assistant Director of Nursing (ADON) acknowledged the absence of annual performance reviews and competencies for nursing staff and the lack of a QAPI for these reviews. The facility also failed to complete a QAPI project for a required 4-hour dementia training. Despite identifying the need for this training in September 2023, the ADON had not documented any progress or benchmarks for the training. Furthermore, the facility did not address ongoing issues with incomplete and inaccurate documentation by nurses and certified nursing assistants, even though these issues were known to the ADON and the Nursing Home Administrator (NHA). Resident Council minutes from October 2023 to March 2024 consistently reported concerns about staff not wearing name badges, long call wait times, and discrepancies between menus and the food served. The Administrator admitted that these concerns should have been addressed through QAPI projects. The Facility's Owner, who is responsible for reviewing the QAPI program, was unaware of these recurring issues and the current QAPI projects. This lack of awareness and action contributed to the facility's failure to maintain an effective QAPI program.
Failure to Develop and Implement Effective QAPI Policies
Penalty
Summary
The facility failed to develop and implement policies addressing how they will use a systematic approach to determine underlying causes of problems impacting larger systems, develop corrective actions designed to effect change at the systems level, develop acceptable performance benchmarks, and monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. The facility's Quality Assurance Performance Improvement Plan (QAPI) Governance and Leadership policy, updated on 8/1/2023, did not include these critical elements. Additionally, the facility's QAPI program failed to implement action plans, measure the success of actions, track performances, and regularly review, analyze, and act on data collected. The facility did not meet regularly to review and analyze data, and failed to maintain documentation of its ongoing QAPI program. Specifically, there were no records of QAPI meetings for the months of March, May, June, and August of 2023. During an interview, the Assistant Director of Nursing (ADON) confirmed that no benchmarks or acceptable parameters were developed for QAPI projects and that she could not locate documentation of specific outcomes, whether benchmarks had been reached, or plans for when benchmarks were not reached.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control standards, particularly droplet precautions, while providing care and housekeeping services in rooms with droplet precautions in place on two of three nursing units. Observations included a CNA providing care to a flu-positive resident without wearing eye protection, a CNA entering a room without donning any PPE, and a housekeeper cleaning a floor in a droplet precaution room without eye protection. Additionally, a nurse entered a droplet precaution room without any PPE, and a CNA assisted a resident with Clostridium Difficile without wearing a protective gown. Interviews with staff revealed a lack of adherence to the facility's infection control policies, with some staff believing PPE use was optional. The facility also failed to have measures in place to prevent the spread of waterborne infections. The facility's Legionella Water Management Program, which is part of the infection prevention and control program, was found to be lacking documentation. The program is supposed to include elements such as an interdisciplinary water management team, a detailed description and diagram of the water system, identification of areas that could encourage the growth and spread of Legionella, and specific measures to control it. However, during an interview, the Assistant Director of Nursing admitted that the facility was unable to locate documentation of the water management program.
Failure to Report Abuse and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to report allegations of abuse for seven residents within the required two-hour time frame. The facility's policy mandates that any suspected abuse, neglect, or theft be reported promptly, but this was not adhered to in multiple instances. For example, Resident #5 reported being forced to take a shower against their will by CNA #16, which was not reported to the state agency in a timely manner. The Director of Nursing (DON) and the Administrator acknowledged that this incident should have been reported immediately, but it was delayed as they waited for the grievance form to be completed. This delay potentially exposed Resident #5 and other residents to further abuse by CNA #16, who was not removed from the nursing schedule immediately after the incident was reported. The facility also failed to provide timely incontinence care for several residents, including Resident #26, Resident #62, Resident #90, Resident #100, Resident #19, and Resident #108. These residents were observed for extended periods without receiving necessary incontinence care, which is a form of neglect. The DON and Administrator were informed of these observations but failed to report the neglect allegations within the required time frame. For instance, Resident #26 was not provided with incontinence care for over four hours on two separate occasions, and this was reported to the Department of Public Health (DPH) approximately 20 hours after the facility was notified of the allegation. The facility's failure to report these incidents promptly and ensure that residents received necessary care highlights significant lapses in adhering to federal and state regulations. The DON and Administrator acknowledged the expectations for reporting and providing care but did not act in accordance with these standards. This resulted in multiple residents experiencing neglect and potential abuse without timely intervention or reporting to the appropriate authorities.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required time frame for two residents. Resident #22, who was admitted to the facility in July 2021 with diagnoses including depression and malnutrition, was admitted to hospice services on January 12, 2024. However, the medical record did not indicate that a significant change MDS was completed within the required time frame following this admission. The Assistant Director of Nursing (ADON) and the MDS coordinator both acknowledged that a significant change MDS should have been completed in January 2024 due to the admission to hospice services. Resident #51, admitted to the facility in August 2022 with diagnoses including dementia, osteoporosis, anxiety, and depression, experienced a fall resulting in fractures on October 4, 2023, and was readmitted to the facility on October 10, 2023. The MDS assessment indicated a decline in the resident's condition, requiring dependency on staff for transfers, toileting, and ambulation. Despite this significant decline in two or more areas, a significant change MDS was not completed. The MDS nurse confirmed that a significant change MDS should have been completed in October 2023 due to the resident's decline in condition.
Failure to Develop and Follow Personalized Care Plans
Penalty
Summary
The facility failed to follow the plan of care and develop personalized care plans for six residents. For Resident #39, the facility did not ensure that Fall Eaze mats were in place on both sides of the bed as ordered by the physician. Despite multiple observations, the mat was consistently missing from the left side of the bed. Interviews with staff revealed a lack of awareness regarding the specific requirements for the resident's fall prevention measures. Resident #49 did not have a cognitive care plan to address dementia, despite having a diagnosis of the condition. Interviews with the Nursing Supervisor and the Assistant Director of Nursing confirmed that a cognitive care plan should have been developed for any resident with dementia. Similarly, Resident #100's care plan was not followed regarding the use of a pressure-relieving boot, and there was no care plan for the resident's diagnosis of Pica, a condition characterized by eating non-nutritive substances. Resident #34, who had contractures of the ankles, did not have a care plan addressing this condition. Interviews with various staff members, including the Physical Therapist and the Director of Nursing, indicated that a care plan should have been developed and periodically revised. Resident #60, who was at high risk for falls, did not have fall mats properly placed as per the care plan. Finally, Resident #71, who had a history of Pica behaviors, did not have a care plan addressing this condition, leading to multiple instances where the resident was observed placing non-edible items in their mouth without proper supervision.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for 16 residents, leading to multiple deficiencies. Specifically, the facility did not ensure feeding assistance and supervision for residents who required it. For instance, Resident #5, who is legally blind and has moderate cognitive impairment, suffered a burn from hot coffee due to lack of supervision during meals. Observations revealed that Resident #5 was repeatedly left alone while eating, contrary to the care plan that required supervision. Similar issues were noted for Residents #50, #60, #82, #97, and #224, who were also left unsupervised during meals despite their need for assistance due to cognitive impairments and other medical conditions like dysphagia and dementia. Staff interviews confirmed that these residents should not have been left alone during meals, and the care plans were not followed as required. The facility also failed to provide adequate incontinence care for several residents. For example, Resident #26, who has severe cognitive impairment and requires full assistance with feeding, was observed eating alone and using his hands to eat food that had fallen on his lap. Staff did not provide the necessary supervision or assistance, leaving the resident to manage on their own. Similar neglect was observed for Residents #62, #90, #19, #100, #108, and #97, who were not provided with timely incontinence care, leading to compromised dignity and hygiene. Staff interviews revealed a lack of adherence to care plans and policies, which mandate prompt response to toileting needs and continuous supervision for residents requiring assistance. Additionally, the facility failed to provide assistance with hygiene for Resident #47. The resident, who is dependent on staff for personal care, was not given the necessary support for maintaining personal hygiene. This neglect was observed during multiple instances, where the resident was left without assistance for extended periods. Staff interviews and care plan reviews indicated that the facility did not follow its own policies and procedures, which require staff to assist residents with hygiene tasks to maintain their dignity and well-being. The overall lack of adherence to care plans and facility policies resulted in significant deficiencies in the quality of care provided to the residents.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for four out of four Certified Nursing Assistants (CNAs) and four out of four licensed nurses whose education records were reviewed. The facility also failed to produce a policy and procedure for ensuring nursing staff competency. During an interview, the Assistant Director of Nursing (ADON) was unable to locate competencies for any of the eight employee records reviewed and did not know who was responsible for oversight of the completion of staff competencies.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete a performance review of Certified Nursing Assistants (CNAs) at least once every 12 months and did not provide regular in-service education based on the outcome of these reviews for 4 out of 4 CNA employee records reviewed. The facility policy titled In-Service Training, Nurse Aide, updated on 8/1/23, indicated that annual in-services are to address areas of weakness as determined by nurse aide performance reviews. During an interview, the Assistant Director of Nursing (ADON) stated that she was unable to locate performance reviews for the 4 CNA records reviewed and did not know who was responsible for the oversight of CNA performance reviews.
Inaccurate Medical Records and Lack of Proper Care
Penalty
Summary
The facility failed to maintain accurate medical records for five residents, leading to several deficiencies. For Resident #122, the medical records contained conflicting information regarding a skin check refusal at a time when the resident was not in the facility. Additionally, there was no documentation of the resident's discharge details, including the discharge order, destination, or physician notification. The Director of Nursing acknowledged the inaccuracies and the lack of proper documentation and follow-up procedures. Resident #26, who has severe cognitive impairment and requires assistance with eating, was observed multiple times without any staff assistance during meals. Despite this, the Certified Nursing Assistants documented that the resident received partial/moderate assistance with eating, which was contrary to the surveyor's observations. Both the Assistant Director of Nursing and the Administrator admitted that the documentation by the CNAs was often inaccurate and incomplete. For Resident #39, who has severe cognitive impairment, the physician's order for fall mats on both sides of the bed was not followed. The resident was repeatedly observed with only one fall mat in place, and the documentation inaccurately indicated that both mats were present. Similarly, Resident #48 did not receive the prescribed Lidocaine patch for wrist pain, although the Medication Administration Report falsely indicated that the patch was applied. Lastly, Resident #84, who requires pressure-relieving booties, was never observed wearing them, despite the Treatment Administration Report showing that the order was completed. The Unit Manager and the Director of Nursing confirmed that orders should not be signed off as completed if not actually done, leading to inaccurate medical records.
Deficiency in CNA Training and Documentation
Penalty
Summary
The facility failed to ensure Certified Nurse's Assistants (CNAs) received the required in-service training. Specifically, the facility did not provide the mandated 12 hours of training per year, did not include dementia management training as required, and did not address areas of weakness identified in CNA performance reviews. This deficiency was identified in the records of four CNAs, where it was found that initial and annual dementia training was either delayed or not conducted at all. For instance, CNA #6 did not receive any education or orientation training since the date of hire, and the initial dementia training occurred three months after hire. Similarly, CNA #5's initial dementia training was delayed by six months, and there was no indication of the number of training hours provided yearly. CNAs #13 and #14 had not received the required annual dementia training since 2014, and their records also lacked documentation of yearly training hours. During interviews, the Assistant Director of Nursing (ADON) acknowledged the deficiencies, stating that the lack of required dementia training was identified in September 2023. Additionally, the ADON admitted to not knowing the total hours of training the CNAs had completed, as the training sign-off sheets and corresponding tests did not document the time spent on each training. This lack of proper documentation and adherence to training requirements highlights significant gaps in the facility's training program for CNAs.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic medications, outlining the risks and benefits of treatment, prior to administering these medications to two residents. Resident #97, who was admitted with severe cognitive impairment and multiple diagnoses including Alzheimer's and major depressive disorder, received several psychotropic medications without proper consent. The medical record review indicated that Resident #97 received 141 doses of Citalopram Hydrobromide, 1 dose of LORazepam Concentrate, 253 doses of LORazepam Concentrate, and 284 doses of QUEtiapine Fumarate without signed consent from the invoked health care proxy. Interviews with the Unit Manager and Assistant Director of Nurses confirmed that the required consents were not on file prior to medication administration, which is against the facility's policy and expectations for psychotropic medication management. Similarly, Resident #82, who was admitted with severe cognitive impairment and diagnoses including dementia with severe agitation and anxiety, also received psychotropic medication without proper consent. The medical record review showed that Resident #82 received 284 doses of Mirtazapine without a signed consent from the invoked health care proxy. Interviews with the Unit Manager and Assistant Director of Nurses revealed that verbal consent is not accepted and that signed consents must be on file prior to the use of psychotropic medications, which was not adhered to in this case. The facility's failure to obtain the necessary consents for these medications constitutes a significant deficiency in their medication management process.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications. The resident, who was admitted in February 2023 with diagnoses including cognitive communication deficit, muscle weakness, and diabetes, had a BIMS score indicating moderate cognitive impairment and was dependent on staff for functional tasks. Despite this, the resident was observed with a tube of Voltaren Arthritis Pain gel on their nightstand and in an open drawer, which they reported using for knee pain. There was no physician's order for the gel, no order to self-administer medication, and no assessment or care plan indicating the resident's ability to self-administer medications. Interviews with the Unit Manager and the Assistant Director of Nursing confirmed that the resident should not have medications in their nightstand and should not be self-administering medications without an assessment and a physician's order. The facility's policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine that they have the decision-making ability to do so safely. This policy was not followed in the case of this resident.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, leading to multiple instances where the resident was unable to call for assistance. The resident, who was admitted with diagnoses including stroke, heart failure, and anxiety, had a moderate cognitive impairment and required assistance for all functional tasks. Despite the facility's policy and the resident's fall care plan indicating that the call light should be within reach, the resident was observed on several occasions calling out for help and water without the call light being accessible. On three separate occasions, the surveyor observed the resident calling out for help and noted that the call light was not within reach. The resident expressed that they would use the call light to ask for help but did not know where it was. Interviews with the Director of Nursing confirmed that the expectation was for call lights to be within reach for all residents who could use them, yet this was not adhered to in the case of this resident.
Failure to Secure Residents' Protected Health Information
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' Protected Health Information (PHI) on two of three nursing units. On multiple occasions, the surveyor observed medication carts with computer screens left open, displaying residents' personal medical information. These incidents occurred on the Glenside and Pond View units, where the screens were visible to residents passing by in the hallway. The nurses responsible for these carts were either not present or had their backs turned, making the information accessible to unauthorized individuals. During interviews, both Nurse #1 and Nurse #2 acknowledged that it was inappropriate to leave the computer screens open, exposing residents' personal medical information. The Corporate Nurse also confirmed that this practice was inappropriate. The facility's policy on Resident Rights, updated on 8/1/23, clearly states that residents have the right to privacy and confidentiality, which was not upheld in these instances.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to the residents and did not file and resolve grievances for three residents out of a total sample of 41 residents. The policy review indicated that the facility should assist residents and their representatives in filing grievances and ensure that all new residents are informed about the grievance process. However, during a resident group meeting, all participating residents expressed that they were unaware of how to file a formal grievance and that grievance forms were not available on any of the three resident units. The last grievance recorded in the facility's log was from October 2023, indicating a significant lapse in the grievance process. Interviews with staff confirmed the absence of grievance forms and the lack of follow-up on reported concerns. Resident #47's daughter reported multiple grievances regarding the resident's care, including not being fed dinner, being put to bed too early, and poor hygiene. Despite these complaints being communicated via email to the Nurse Unit Manager, no formal grievances were filed, and the issues were not resolved. The Administrator acknowledged that these concerns should have been addressed through the formal grievance process but was unaware that no grievances had been filed since October 2023. The Nurse Unit Manager admitted to not using grievance forms and only addressing issues verbally due to time constraints. Resident #100's daughter also reported multiple grievances, including the resident being left unsupervised with non-edible items, delayed notification to the physician about a potential stomach bleed, and the resident being dressed in the wrong clothing. Similar to Resident #47, these complaints were not filed as formal grievances, and no resolutions were documented. The Administrator and Nurse Unit Manager both acknowledged the failure to follow the grievance process. Additionally, Resident #5's family member reported the loss of the resident's dentures and the lack of follow-up on the claim. Again, no formal grievance was filed, and the issue remained unresolved. The Administrator confirmed that such concerns should have been formally addressed but were not due to lapses in the grievance process.
Failure to Prevent Unauthorized Use of Restraints
Penalty
Summary
The facility failed to prevent the use of restraints without appropriate assessment for Resident #101. The resident, who was admitted with multiple diagnoses including bell's palsy, gastroesophageal reflux disease, and bipolar disorder, was observed on two occasions with blankets and pillows stuffed under the fitted sheet on both sides of the mattress. This setup restricted the resident's movement and was not documented as a restraint in the medical record or care plan. The facility's policy on restraints requires a pre-restraining assessment, a physician's order, and consent from the resident or representative, none of which were followed in this case. Interviews with staff revealed that the use of blankets and pillows under the fitted sheet was intended to prevent falls and provide comfort, but it was not recognized as a restraint. The Director of Nursing confirmed that such an arrangement should be considered a restraint and that residents should be assessed accordingly. The medical record and care plan for Resident #101 did not indicate the use of a restraint or any assessment for such, highlighting a failure to adhere to the facility's restraint policy.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement their abuse policy for a resident who reported being forced to take a shower against their will by a Certified Nursing Assistant (CNA). The resident, who had moderate cognitive impairment and required substantial assistance with bathing, reported that the CNA ignored their requests to not take a shower, sprayed water in their face, and used an excessive amount of shampoo. The incident was reported to a private duty aide and subsequently to the resident's family member, who filed a formal complaint with the Director of Nurses (DON) on the same day. Despite being notified of the incident, the DON did not take any further action to investigate or report the abuse allegation within the required two-hour timeframe to the Department of Public Health's Health Care Facility Reporting System (HCFRS). The Unit Manager confirmed that the family member had informed her of the incident, and she had notified the DON. However, the DON admitted to not recalling the incident initially and later acknowledged being aware of it but failing to act. The Nursing Home Administrator (NHA) and Nurse Consultant also acknowledged that the incident should have been handled as an abuse allegation, including a full investigation and timely reporting. The abuse allegation was eventually submitted to HCFRS nine days after the initial report, indicating a significant delay in addressing the issue as per the facility's abuse policy and federal requirements.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents, leading to deficiencies in care. Resident #5, who has moderate cognitive impairment, reported that a CNA forced them to take a shower against their will, causing emotional distress. Despite the resident and their family reporting the incident to the Unit Manager and the DON, no formal investigation or grievance report was completed. The DON acknowledged that the CNA should not have forced the shower and that an investigation should have been conducted, but no actions were taken to address the abuse allegation or remove the CNA from the schedule. Resident #47, who has severe cognitive impairment, had multiple complaints of neglect reported by their daughter. The daughter emailed the facility expressing concerns about the resident's safety and care, but no investigative reports were produced. The Administrator confirmed that any allegations of neglect should be investigated but could not explain why an investigation was not completed, as the incident occurred before their tenure. The facility's failure to investigate these allegations of abuse and neglect exposed the residents to potential harm and emotional distress. The lack of timely and appropriate response to these serious concerns highlights significant deficiencies in the facility's handling of abuse and neglect reports.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a copy of the transfer/discharge notice upon transfer to the hospital for one resident out of a total sample of 41 residents. Resident #121, who was admitted to the facility in January 2024 with diagnoses including Covid-19 and heart failure, was discharged to the hospital on January 10, 2024. A review of the medical record indicated that the required transfer/discharge notice was not given to Resident #121 or their representative. During an interview on March 6, 2024, the Director of Nursing confirmed that the transfer/discharge notice for Resident #121 could not be located and acknowledged that it should have been provided to the resident or their representative.
Failure to Complete Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to complete quarterly care plan meetings for two residents, leading to deficiencies in their care. Resident #48, who is cognitively intact and requires assistance for all functional daily tasks, had not had a care plan meeting for over three months. During a resident group meeting, multiple residents, including Resident #48, expressed that they were unaware of care plan meetings and had not been informed of when these meetings would occur. The Social Worker and Receptionist confirmed that care plan meetings were scheduled without the Social Worker's attendance, and the Administrator acknowledged that meetings should be held quarterly according to the MDS schedule. Resident #51, who has moderate cognitive impairment and is dependent on staff for daily tasks, had not had a care plan meeting since their readmission following a hip fracture. The resident's medical record indicated a significant decline in mobility and self-care, yet no care plan meeting had been documented since the incident. The facility provided a late entry note for a care plan meeting that allegedly took place, but it lacked details on the interdisciplinary team's presence. The MDS Nurse confirmed that there were no notes to verify if the scheduled care plan meeting had occurred, indicating a lapse in the facility's care planning process.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that staff administered medication in a manner that met professional standards of care for one resident. Specifically, staff did not apply lidocaine patches to the resident's right wrist and right knee as per the physician's order. The resident, who was cognitively intact and had a diagnosis of osteoarthritis, reported that the patches were not applied on the day of the survey, causing discomfort. The Medication Administration Record (MAR) did not indicate that the patches were administered, nor was there any documentation of the resident refusing the treatment. During interviews, Nurse #4 confirmed that the patches were not applied and that the resident had not refused the medication. The Assistant Director of Nursing (ADON) stated that medications and treatments should be administered at the specified times and that any refusals should be documented. The facility's policy on administering medications, updated in August 2023, was not followed in this instance, leading to the deficiency.
Failure to Provide Adequate Activities Program
Penalty
Summary
The facility failed to provide an activities program that met the interests and supported the physical, mental, and psychosocial well-being of Resident #54. The resident, who was admitted with a diagnosis of an unspecified fracture of the left calcaneus and had severe cognitive impairment, expressed feelings of boredom and a desire to participate in activities. Despite the resident's interest in music, movies, live entertainment, and religious activities, the facility did not provide a care plan specific to the resident's activity preferences. Additionally, the resident did not receive a handheld copy of the activities calendar and was unable to see the calendar posted on the bathroom door from the bed. Observations over several days revealed that Resident #54 remained in bed without engagement in scheduled activities such as the rosary, morning greeting, daily chronicle, and mass. The resident's television was often off, and there were no handheld activities like reading materials or puzzles available in the room. Staff did not offer to take the resident to activities or provide one-on-one visits, despite the resident's expressed interest and the facility's policy requiring such actions. Interviews with staff, including the Activities Director and Activities Assistant, confirmed that there was no system in place to track resident participation in activities since November 2023. The Activities Director acknowledged that all residents should have a care plan developed specific to activities, including preferences and religious denomination. The lack of a tracking system and failure to offer activities to Resident #54 contributed to the resident's lack of engagement and dissatisfaction with the activities program.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment for two residents, leading to significant risks of choking and burns. For Resident #71, who has a diagnosis of Pick's disease, aphagia, and dementia, the staff failed to provide continual supervision. This resident was observed multiple times placing non-edible items, such as small plastic balls, a plastic bag, and a sugar packet, into their mouth. Despite the known choking risk and the requirement for constant supervision, the resident was left unsupervised on several occasions, including during meals. Staff were either unaware of the resident's actions or failed to intervene promptly, leading to repeated incidents of the resident placing hazardous items in their mouth. For Resident #12, who has diagnoses including dysphagia, anxiety, and dementia, the staff failed to provide adequate supervision while the resident was consuming hot coffee. The resident, who requires continual supervision and assistance with eating, was observed reaching for and spilling hot coffee twice. On one occasion, the resident spilled hot coffee onto their wheelchair and the floor while being pushed by staff. On another occasion, the resident, left unsupervised in the dining room, picked up a cup of hot coffee with a shaking hand, causing it to spill onto the table. The temperature of the coffee was tested at 165 degrees Fahrenheit, posing a significant risk of burns. Interviews with staff, including the Unit Manager, Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that both residents required constant supervision due to their conditions. However, the facility failed to ensure that these supervision requirements were met, leading to repeated incidents that put the residents at risk. The facility's policies and care plans were not adequately followed, resulting in a failure to prevent these accidents and incidents.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for a resident with dementia, who had moderate cognitive impairment. The resident expressed that their teeth hurt at times and they could not remember the last time they were seen by a dentist. Despite a consent form and a physician order for dental services being in place since March 2022, the resident's medical record and the dental visit summary log for 2023 indicated that the resident had not been seen by a dentist in the past year. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the facility's expectation is for all residents who have consented to be seen by the dentist to receive dental services. However, the ADON was unaware that the resident had not been seen by a dentist in 2023, indicating a lapse in the facility's adherence to its own dental services policy.
Failure to Provide Correct Therapeutic Diets
Penalty
Summary
The facility failed to provide the correct ordered therapeutic diet to ensure safety while eating for three residents. Resident #19, who has severe cognitive impairment and dysphagia, was observed eating regular textured vegetables instead of the prescribed pureed vegetables. Despite the physician's order and the nutritional care plan specifying a ground diet with pureed fruits and vegetables, the resident received the wrong texture for three meals. The nursing staff admitted to not thoroughly checking the meal trays, and the Food Service Director was unaware of the error until the surveyor's observation. Resident #5, diagnosed with dysphagia and moderate cognitive impairment, was also not provided with the correct diet. The resident was observed eating regular textured toast, fried fish, and collard greens instead of the prescribed ground diet. The meal tickets were not updated to reflect the diet change, and the nursing staff failed to notice the incorrect diet being served. The Director of Nursing confirmed the discrepancy and emphasized the need for nurses to check meal trays before serving. Resident #60, with severe cognitive impairment and dysphagia, was observed eating regular textured foods such as toast, potato chips, and hard candies, contrary to the prescribed ground diet. The resident's meal tickets indicated a ground diet, but the actual food served did not comply with this order. The nursing staff and Food Service Director were unaware of the errors, and the Speech Language Pathologist highlighted the lack of supervision during meals as a contributing factor. The Unit Manager also noted that the resident should not be given certain foods brought in by family members without proper assessment.
Failure to Ensure Proper Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that hospice services met professional standards and principles, and did not have a written agreement with the hospice signed by authorized representatives before hospice care was furnished to residents. Specifically, the facility did not develop coordinated person-centered care plans with individualized interventions for the provision of hospice care services and failed to ensure ongoing documentation of hospice staff visits for two residents. Additionally, the facility did not obtain a physician's order for the provision of hospice care for one resident and lacked a signed written agreement with the hospice provider before services were rendered to any resident. For Resident #58, the facility's medical record did not indicate that hospice was communicating with the facility during visits, and there was no documentation of hospice visits. The hospice care plan was not included in the medical record until several months after the resident was admitted to hospice care. Furthermore, there was no consent for hospice to admit or treat Resident #58 in the medical record. The Assistant Director of Nursing (ADON) confirmed that unit managers are responsible for overseeing hospice care and ensuring ongoing communication with hospice providers, which was not done in this case. For Resident #97, the facility's medical record also lacked documentation of hospice communication and visits. There was no consent for hospice to admit or treat the resident, and no physician's order for hospice services was obtained. The hospice binder, which should have contained information regarding care needs, care plans, and services provided by the Home Health Aide (HHA), was empty. The Director of Nursing (DON) confirmed that hospice residents should have an order for hospice at the start of care and that the facility must have a signed contract for hospice services, which was not present for Resident #97. The ADON and Administrator could not locate a hospice contract during the survey.
Failure to Implement and Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff members as required by the facility assessment. Specifically, the facility did not provide the necessary training to meet the needs of each resident. The review of the Facility Assessment indicated that staff training, education, and competencies were to be provided upon hire and annually, with continuous education and training facilitated by a full-time registered nurse serving as the Staff Development Coordinator (SDC). However, the review of employee records for four nursing assistants and four licensed nurses revealed a lack of yearly competencies and mandatory training, including effective communication, resident rights, abuse, neglect, and exploitation. During an interview, the Assistant Director of Nursing (ADON) admitted to being unable to locate the competencies for the eight employee records reviewed and was unaware of who was responsible for overseeing staff competencies. No further educational documents were provided during the survey, indicating a systemic failure in maintaining the required training program to meet the residents' needs as outlined in the facility assessment.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a copy of the bed-hold notice upon transfer to the hospital for one resident out of a total of 41 sampled residents. According to the facility's policy, all residents or their representatives should receive written information regarding bed-hold policies at the time of transfer or within 24 hours if the transfer was an emergency. Resident #121, who was admitted in January 2024 with diagnoses including Covid-19 and heart failure, was discharged to the hospital on January 10, 2024. However, a review of the medical record indicated that neither the resident nor their representative received the required bed-hold notice. During an interview, the Director of Nursing confirmed that the bed-hold notice for Resident #121 could not be located and acknowledged that it should have been provided.
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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