Meadows Of Central Massachusetts (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochdale, Massachusetts.
- Location
- 111 Huntoon Memorial Highway, Rochdale, Massachusetts 01542
- CMS Provider Number
- 225668
- Inspections on file
- 17
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Meadows Of Central Massachusetts (the) during CMS and state inspections, most recent first.
The facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, and did not designate a full-time Director of Nursing (DON) who is a RN. The DON worked only 32 hours per week, and an LPN covered the remaining days. The facility had no staffing waivers in place.
A resident with multiple medical conditions did not receive timely administration of critical medications, including pain relief, IV antibiotics, anticoagulants, and anticonvulsants, as ordered by the physician. The resident was observed in severe pain, and interviews revealed a misunderstanding of the facility's medication administration policy, leading to significant delays in care.
A resident with a urinary catheter experienced gross hematuria, but the facility failed to notify the Physician or NP in a timely manner. Despite observations of bloody urine, the staff did not have specific orders for catheter care, and communication lapses led to a delay in intervention. The resident, with a history of urinary retention and on anticoagulant medication, was eventually hospitalized due to the lack of prompt action.
A resident with quadriplegia was unable to access their call device due to improper placement, despite being dependent on staff for care. The call pad, necessary for alerting staff, was found dangling below the bed, out of reach. Staff interviews confirmed the resident's inability to use the device, highlighting a failure to provide a homelike environment.
A resident with Traumatic Brain Injury and contractures did not have a care plan updated to include recommended positioning interventions. Despite recommendations for a specialty wheelchair with molded lateral supports, the resident was observed in a Geri chair without these supports. Staff interviews revealed a lack of communication and implementation of the recommended interventions, leading to ineffective positioning.
A facility failed to provide proper urinary catheter care for three residents, leading to increased risks of complications. One resident was admitted with a catheter but lacked physician orders for its care, resulting in unaddressed hematuria. Another resident had an external catheter without a physician's order, and a third resident received a catheter of the wrong size, contrary to medical instructions.
A resident requiring Total Parenteral Nutrition (TPN) did not receive Clinimix E and SMOFlipids as ordered, due to a failure by the nursing staff to administer the infusions correctly. The resident's infusions were not completed on schedule, and the staff did not take appropriate steps to address the issue, such as consulting with the pharmacy or obtaining new orders. The Assistant Director of Nursing, Dietitian, and Nurse Practitioner were not informed of the missed infusions, resulting in the resident not receiving the necessary nutrition and hydration.
A resident with severe pain did not receive scheduled pain medications on time, resulting in prolonged discomfort. The resident, dependent on staff for pain relief, was observed crying in bed with their call device out of reach. Medications due between 8:00 A.M. and 9:00 A.M. were not administered until after 11:00 A.M., despite the resident's report of severe pain. The ADON confirmed that the medications were time-critical and should have been administered within one hour of the scheduled time.
A resident with a Stage 4 Pressure Ulcer was prescribed Clindamycin for seven days, but the MAR indicated administration for 12 days. The medication was not delivered from the pharmacy, leading a nurse to borrow it from another resident, contrary to facility policy. Interviews revealed staff were unaware of the prohibition on borrowing medications.
The facility failed to properly label and store medications, as observed with an Albuterol inhaler lacking a pharmacy label on a medication cart. Nurse #5 was unaware of when the inhaler was opened and confirmed the absence of necessary labeling. The ADON acknowledged the labeling deficiency.
The facility failed to implement infection control measures for two residents and on one unit. A resident with a Stage 4 Pressure Ulcer did not receive care under Enhanced Barrier Precautions, and a PICC line dressing change was not performed according to policy. Additionally, a glucometer was not disinfected between uses, contrary to facility expectations.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of the PBJ Staffing Data Report for Quarter 3 of 2024, which indicated that there were four or more days within the quarter with no RN hours. Specifically, the facility did not have an RN on duty for eight hours on 4/27/24, 5/12/24, and 6/21/24. During an interview, the Administrator confirmed that no RNs worked on these days and acknowledged that the facility did not have any staffing waivers in place. Additionally, the facility failed to designate a Registered Nurse to serve as the Director of Nursing (DON) on a full-time basis. The DON, who is a RN, worked only 32 hours per week, covering Monday through Thursday, while the Assistant Director of Nursing (ADON), who is not a RN, covered the remaining days. The Administrator confirmed that the facility did not have any waivers for staffing in place, and the ADON, a Licensed Practical Nurse (LPN), stated that staff would approach her with clinical problems or questions on the days the DON was not present.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. The resident, who was admitted with multiple diagnoses including chronic embolism, thrombosis, and unspecified convulsions, did not receive timely administration of several critical medications. These included pain medications, intravenous antibiotics, anticoagulants, and anticonvulsants, all of which were ordered by the physician to be administered at specific times to manage the resident's conditions effectively. On the day of the survey, the resident was observed in bed, crying and reporting severe pain, indicating that the scheduled pain medications had not been administered on time. The resident also reported that the intravenous antibiotic medication, crucial for treating an active infection, had not been administered as scheduled. The surveyor noted that the resident's call device was out of reach, and upon activation, the nurse confirmed the delay in medication administration. Interviews with the unit manager and assistant director of nursing revealed a misunderstanding of the medication administration policy, which requires medications to be given within one hour of the scheduled time. The unit manager admitted to administering the resident's medications late, including pain and IV antibiotic medications. The assistant director of nursing emphasized the critical nature of timely medication administration for the resident's conditions, highlighting the facility's failure to adhere to its own policies and the physician's orders.
Failure to Notify Physician of Resident's Catheter Bleeding
Penalty
Summary
The facility failed to timely notify the Physician or Nurse Practitioner of a change in the condition of a resident with a urinary catheter, leading to hospitalization for gross hematuria. The resident, who had a history of urinary retention and was on anticoagulant medication, was observed with bloody urine in the catheter tubing. Despite this observation, the facility did not have any specific orders for the care and maintenance of the Foley catheter, and the bleeding was not promptly reported to the Physician. The resident was admitted with a Foley catheter due to urinary retention and had a history of chronic kidney disease and Parkinson's disease. The catheter was observed to have bloody urine, but the facility staff failed to notify the Physician in a timely manner. Nurse #3 was informed by a CNA about the bloody urine but did not have time to notify the Physician and instead asked another nurse to do so. However, the nurse responsible for the resident's care was unaware of the catheter and the bleeding. The Unit Manager and the facility's NP were not aware of the resident's condition until later. The NP was informed of the hematuria but was not made aware of its severity, leading to a delay in appropriate intervention. The resident's condition was eventually reported, and orders were given to hold the anticoagulant medication and to transfer the resident to the hospital after a significant delay. This lack of timely communication and intervention resulted in the resident's hospitalization.
Failure to Ensure Accessible Call Device for Resident
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring ready access to a call device for a resident who was dependent on staff for care needs. The resident, who had quadriplegia due to a spinal injury, was cognitively intact and required substantial assistance for daily activities. The resident's care plan indicated the need for an alternative call pad device, which could be activated by tapping, to alert staff for assistance. However, the call pad device was not positioned within the resident's reach, as observed by the surveyor, leading to the resident's inability to call for help when needed. During observations, the call pad device was found dangling below the bed, out of the resident's reach, and not positioned on the mattress near the resident's left hand as required. Interviews with the resident and staff confirmed that the resident was unable to locate or use the call pad device due to its improper placement. The Assistant Director of Nursing acknowledged that the resident was dependent on staff to position the call pad device correctly, which was necessary for the resident to alert staff for assistance.
Failure to Implement Recommended Positioning for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with limited range of motion, specifically regarding positioning after recommendations were made by Rehabilitative Services. The resident, who was admitted with diagnoses including Traumatic Brain Injury and multiple contractures, was assessed by Rehabilitative Services, which recommended a specialty wheelchair with molded lateral supports. However, these recommendations were not incorporated into the resident's care plan. Observations revealed that the resident was seated in a Geri chair with various supports, but not in the recommended tilt-in-space chair with molded lateral supports. Interviews with staff, including the Rehabilitation Director and nursing personnel, indicated a lack of communication and implementation of the recommended interventions. The Rehabilitation Director noted that the resident's current positioning was ineffective, and the recommended interventions were not in place. Further interviews with nursing staff and the Unit Manager highlighted a breakdown in the process of updating the care plan and educating staff on new positioning needs. The Unit Manager and Nurse #6 were unaware of any specialty positioning devices for the resident, and there was confusion about whether a tilt-in-space chair had been ordered. This lack of coordination and follow-through resulted in the resident not receiving the appropriate care as recommended by Rehabilitative Services.
Deficiencies in Urinary Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and services according to professional standards for three residents, leading to increased risks of complications. Resident #210 was admitted with a urinary catheter, but the facility did not identify this upon admission, resulting in delayed monitoring and assessment. There were no physician orders for the care and maintenance of the Foley catheter, and the resident exhibited hematuria, which went unaddressed due to a lack of communication among the nursing staff. Resident #42 had an external urinary catheter but lacked a physician's order for its use. This oversight indicates a failure to ensure that all necessary medical orders were in place for the resident's care. The absence of a physician's order for the external catheter suggests a lapse in the facility's protocol for managing urinary catheters, which could potentially lead to inappropriate or inadequate care. Resident #44 had a suprapubic catheter inserted, but the size did not match the physician's order. The facility staff inserted a 20 French catheter instead of the ordered 16 French, indicating a failure to adhere to specific medical instructions. This discrepancy highlights a lack of attention to detail in following physician orders, which is critical for ensuring the safety and well-being of residents requiring catheterization.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to provide care and services for assisted nutrition and hydration in accordance with the Physician's order for a resident who required Total Parenteral Nutrition (TPN). The resident, admitted with diagnoses including Unspecified Intestinal Obstruction and Gastro-Esophageal Reflux Disease, required TPN indefinitely due to a high risk for re-obstruction. The Physician's order specified the administration of Clinimix E and SMOFlipids, which were not provided as ordered, increasing the resident's risk for malnutrition. On the evening of October 9th, the resident was supposed to receive 2000 mL of Clinimix E and 50 grams of SMOFlipids, but the infusions were not completed as scheduled. The Clinimix E infusion was still running at a reduced rate the following afternoon, and the SMOFlipids were not reconnected after being stopped for a lab draw. Nurse #7, who was responsible for the infusions, failed to reconnect the SMOFlipids and did not know why they should not be reconnected. The nurse also did not take appropriate steps to address the leftover infusions, such as consulting with the pharmacy or obtaining new orders from a physician. The Assistant Director of Nursing (ADON) and the Dietitian were not informed of the missed infusions, and the Nurse Practitioner (NP) was not contacted to adjust the orders. The facility staff did not alert the Dietitian about the resident's low protein levels or the need for a consult, and the NP was unaware of the issue due to a lack of communication from the staff. This lack of communication and failure to follow the Physician's orders resulted in the resident not receiving the necessary nutrition and hydration as prescribed.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management interventions for a resident experiencing severe pain. The resident, who was admitted with conditions including unspecified cord compression, muscle spasms, and cutaneous abscesses, was dependent on staff for both pharmacological and non-pharmacological pain relief. The facility's policy on pain management emphasized the importance of individualized assessment and timely intervention, yet the resident did not receive scheduled pain medications on time. On the day of the incident, the resident was observed in bed, crying, with their call device out of reach. The resident reported to the surveyor that they had not received their scheduled pain medications, which were due between 8:00 A.M. and 9:00 A.M. The medications were not administered until after 11:00 A.M., despite the resident's report of severe pain. The Unit Manager, responsible for administering the medications, acknowledged the delay and confirmed that the resident reported a pain level of eight out of ten prior to receiving the medications. Interviews with the Assistant Director of Nursing (ADON) revealed that the resident frequently experienced pain and that their medications were considered time-critical. The ADON stated that the medications should have been administered within one hour of the scheduled time to effectively manage the resident's pain. The delay in administering medications resulted in the resident experiencing prolonged severe pain until the medications were finally given.
Medication Administration Error with Clindamycin
Penalty
Summary
The facility failed to ensure that a resident was free of medication errors, specifically regarding the administration of the antibiotic Clindamycin. The resident, who was admitted with a diagnosis of a Stage 4 Pressure Ulcer, was prescribed Clindamycin to be administered four times a day for seven days. However, the Medication Administration Record (MAR) indicated that the medication was administered for 12 days, contrary to the physician's order. The error was compounded by the fact that the Clindamycin was not delivered from the pharmacy as expected. As a result, a nurse borrowed the medication from another resident's supply, unaware that this practice was not permitted. Interviews with nursing staff revealed a lack of awareness and adherence to the facility's medication management policy, which prohibits borrowing medications from other residents and requires medications to be dispensed by the pharmacy.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional principles. During a review of the medication cart on the First Floor, a surveyor and Nurse #5 found an Albuterol Sulfate inhalation aerosol unit stored in a ziplock bag without a pharmacy label. The label should have included the prescribed dose, strength, expiration date, route of administration, and instructions and precautions. Instead, the bag and the side of the inhaler had a resident's name and room number handwritten in black marker. Nurse #5 admitted to not knowing when the inhaler was opened and acknowledged the absence of a label or date on the bag or inhaler. Although she knew which resident the inhaler was for, she confirmed that there should have been a pharmacy label with instructions. She also mentioned that she had not administered the inhaler and intended to dispose of it. The Assistant Director of Nursing (ADON) later confirmed that the inhaler should have been labeled with the required information and should not have been on the medication cart.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control measures for two residents and on one unit. Resident #6, who was admitted with a Stage 4 Pressure Ulcer, did not receive care under Enhanced Barrier Precautions (EBP) as required. During a wound dressing change, Nurse #4 did not wear a gown, failed to sanitize hands before donning gloves, and used scissors from her pocket without proper hand hygiene. Nurse #4 was unaware of the EBP requirement due to the absence of signage indicating the necessary precautions. Resident #46, admitted with an Unspecified Intestinal Obstruction, was due for a PICC line dressing change. During the procedure, Unit Manager #1 did not follow the facility's infection control policy. She initially forgot to wear a mask, did not sanitize her hands between glove changes, and failed to don a new gown after leaving and re-entering the resident's room. These lapses occurred despite the resident's reminder and the facility's policy requirements. Additionally, the facility did not ensure proper disinfection of a glucometer between resident uses. Nurse #7 performed a blood glucose check and placed the glucometer back on the medication cart without disinfecting it. He intended to clean it after completing medication administration for all residents, contrary to the expectation of disinfecting the device after each use. This oversight was acknowledged by both Nurse #7 and Unit Manager #1, who confirmed the facility's policy on glucometer disinfection.
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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