Medway Country Manor Skilled Nursing & Rehabilitat
Inspection history, citations, penalties and survey trends for this long-term care facility in Medway, Massachusetts.
- Location
- 115 Holliston Street, Medway, Massachusetts 02053
- CMS Provider Number
- 225412
- Inspections on file
- 31
- Latest survey
- February 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Medway Country Manor Skilled Nursing & Rehabilitat during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment was involved in an incident where a CNA made threatening comments. The Activity Assistant reported this to the Activity Director, who failed to notify the administration immediately, violating the facility's Abuse Policy. The delay in reporting was confirmed during interviews with staff.
A resident with moderate cognitive impairment was verbally threatened by a CNA, who suggested harm. The incident was reported late to the facility administration and subsequently to the DPH, missing the required two-hour reporting window. The Administrator misunderstood the reporting process, leading to a three-day delay.
The facility failed to ensure proper use of PPE for residents on transmission-based precautions, with staff entering rooms without required gowns or gloves. Additionally, a staff member with a positive GAS test continued working without exclusion, risking infection spread. The DON and Infection Preventionist lacked awareness of residents' precautionary needs, leading to deficiencies in infection control.
A resident tested positive for Group A Streptococcal (GAS) in their left shoulder, but the LTC facility failed to notify the physician promptly, delaying notification by four days. This delay resulted in a failure to initiate timely contact precautions, potentially exposing other residents and staff to the infectious disease. The facility's policy requires immediate notification of such results, which was not adhered to, indicating a breakdown in communication protocols.
The facility failed to enforce infection control protocols after a CNA tested positive for Group A Streptococcal (GAS). Despite policy requiring 24 hours of antibiotic therapy before returning to work, the CNA continued working across units, risking disease spread. The DON did not inform the CNA or scheduler of work restrictions, and the IP did not follow up on test results, leading to potential exposure risks.
The facility failed to maintain an effective infection control program, resulting in delayed precautions and treatment for a resident with GAS, incomplete documentation for another resident with sepsis and GAS bacteremia, and non-compliance with PPE use by staff. Additionally, a staff member with GAS continued working before completing the required antibiotic treatment, increasing the risk of further transmission.
The facility failed to ensure nursing staff demonstrated appropriate competencies, particularly in dietary management for residents with dysphagia. Observations showed residents were served meals not prepared according to prescribed dietary requirements, posing safety concerns. Interviews revealed a lack of understanding and adherence to dietary policies, and the facility's training and competency evaluation processes were inadequate.
The facility did not conduct annual performance reviews or provide in-service training based on these reviews for three CNAs. The policy requires regular in-service education and annual performance reviews, but files for three CNAs lacked performance evaluations. The Administrator confirmed the absence of a process for these reviews and no staff assigned to conduct them.
The facility failed to ensure CNAs completed the required 12 hours of annual training, including dementia care and abuse prevention. Staff interviews and record reviews revealed inadequate documentation and tracking of training hours. The facility's policy mandates regular in-service education and performance reviews, but these were not properly documented or followed.
The facility failed to ensure timely physician visits for three residents, with significant gaps between required visits. A resident went 106 days without a visit, another 91 days, and a third 104 days, contrary to regulations requiring alternating visits between a physician and NP every 30 to 60 days. The DON acknowledged the oversight, and no additional documentation was provided.
The facility failed to provide sufficient support personnel with appropriate competencies and skills in food and nutrition services. Observations showed meals were not prepared according to dietary textures, and meal tickets were not accurately followed. The FSD was unaware of inconsistencies, and there was no documentation of dietary staff competencies. The SLP noted that diet changes were not consistently maintained, and therapeutic diets were not included in orientation.
The facility failed to provide meals in the appropriate modified texture for residents with specific dietary needs, such as those with dysphagia. Meals intended for ground or chopped diets were served with whole pasta and large pieces of food, contrary to physician orders. Staff lacked understanding of diet textures, leading to potential safety concerns for residents with swallowing difficulties.
The facility failed to maintain sanitary conditions in the main kitchen, with issues such as gaps in baseboard molding, debris buildup, and black growth on walls. The walk-in refrigerator and dry storage room also had significant cleanliness issues, including soiled shelves and mouse droppings. Interviews with the FSD and dietary staff revealed a lack of adherence to cleaning schedules, and the DON emphasized the need for clean and sanitary kitchen operations.
The facility failed to administer pneumonia vaccines to 12 residents who had consented to receive them. Despite having a policy in place, the vaccines were not given by the specified date. The Infection Preventionist acknowledged the oversight and noted that the facility had just ordered the vaccines, planning to administer them upon arrival.
A facility failed to develop and implement a care plan for a resident with spinal stenosis and pain, despite the resident's cognitive awareness and ongoing pain management interventions. Interviews revealed that while the resident received medications and therapy, there was no documented care plan addressing their pain management needs.
A resident with pneumonia received 14 additional doses of levofloxacin due to a transcription error in the medication orders. The resident, who was cognitively intact and had diagnoses including diabetes and end-stage renal disease, was supposed to receive a specific dosage schedule. However, the error led to the administration of 17 doses instead of the prescribed three, as confirmed by the Unit Manager and DON.
A resident with peripheral vascular disease and arterial wounds on the right foot did not receive prescribed wound treatments, including Santyl and Calcium Alginate applications. Observations showed the wounds were left uncovered, and the responsible nurse was unaware of the full treatment orders, despite documentation indicating completion. The DON confirmed treatments should be completed and documented accurately.
A resident with chronic low back pain did not receive appropriate pain management due to the facility's failure to implement a physiatrist's recommendation to increase gabapentin dosage. Despite approval from a nurse practitioner, the order was not executed, leaving the resident on a lower dosage and experiencing unmanaged pain.
A facility failed to ensure safe dialysis care for a resident with end-stage renal disease by not developing a comprehensive care plan, lacking communication with the dialysis center, and delaying physician's orders for access site monitoring. The resident was unaware of communication processes, and there was no documentation of pre- and post-dialysis weights.
A facility failed to identify and document PTSD triggers for a resident with a history of trauma, despite the resident expressing fear when another resident wandered into their room. The care plan included interventions for PTSD, but no specific triggers were identified or discussed with the resident's representative, leading to potential re-traumatization.
The facility failed to include monthly medication regimen review (MRR) reports in the medical records for two residents, despite the Consultant Pharmacist completing the reviews. The reports, which should have included recommendations and the Physician's response, were not available in the residents' charts. Instead, they were stored in the DON's office, and some reports were missing. This indicates a lapse in the facility's process for documenting and maintaining MRR reports.
A resident received 17 doses of levofloxacin instead of the prescribed three doses due to a transcription error in the physician's order. The resident, who was cognitively intact and diagnosed with pneumonia, received unnecessary additional administrations of the antibiotic. The error was identified by the Unit Manager, and the DON confirmed the need for accurate transcription of orders.
A facility failed to limit a resident's PRN antipsychotic medication to 14 days or provide a documented rationale for extending its use. The resident, with depression and dementia, received Risperdal for agitation without reevaluation after 14 days, contrary to facility policy. The DON confirmed the expectation for reevaluation.
A nurse in the facility committed three medication errors out of 27 opportunities, resulting in an 11.11% error rate. One resident did not receive prescribed medications due to unavailability, and the nurse failed to notify the provider. Another resident received a saline flush without a physician's order. The facility's policy requires physician notification and orders for all treatments, which were not followed in these instances.
The facility failed to store drugs and biologicals properly, with the East Unit medication refrigerator's temperature recorded only once daily instead of twice, as required. Additionally, controlled substances like Lorazepam were not stored in permanently affixed compartments, allowing unauthorized access by multiple nurses. The DON confirmed these practices were against the facility's policy.
A facility failed to secure a handrail in a corridor, posing a safety hazard. The maintenance log showed the issue was reported but not addressed. Observations confirmed the handrail was loose, with broken plaster and holes. The Maintenance Director, working alone, was unable to conduct frequent rounds. A resident reported the handrail had been broken for weeks. The Administrator acknowledged the risk and expected repairs.
A facility failed to obtain informed consent from a resident's Health Care Agent before administering psychotropic medications. The resident, with dementia and an activated Health Care Proxy, received Amitriptyline HCL and Quetiapine Fumarate without the required consent. The facility's policy and state regulations mandate informed consent, but documentation was missing, as confirmed by interviews with the Health Care Agent and Administrator.
A resident's family reported an allegation of sexual abuse by a staff member, but the facility failed to suspend the implicated CNAs during the investigation, as required by policy. Miscommunication between the DON and ADON led to a delay in the investigation. Additionally, the facility did not conduct required NAR and CORI checks for the CNAs before hiring, violating hiring policies.
A resident's family reported an allegation of sexual abuse to the DON and ADON, but due to miscommunication, the report was not submitted to the DPH within the required two-hour timeframe. The facility's policy mandates immediate reporting of such allegations, which was not followed.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement and follow its Abuse Policy when an allegation of verbal abuse was not immediately reported to the administration. On January 18, 2025, an incident occurred involving a resident with moderate cognitive impairment who was dependent on staff for care. During this incident, a CNA made threatening and inappropriate comments about the resident to an Activity Assistant, suggesting harm. The Activity Assistant reported the incident to the Activity Director, but the Director did not notify the administration until two days later, contrary to the facility's policy requiring immediate reporting. The facility's Abuse Policy, although untitled and undated, clearly states that upon receiving an allegation of abuse, staff must take necessary steps to protect residents and immediately notify the Administrator. However, the Activity Director delayed reporting the verbal abuse allegation, which was confirmed during interviews with the Activity Assistant, the Director of Nurses, and the Administrator. This delay in reporting was acknowledged by the Activity Director, who admitted that the allegation should have been reported immediately, as per the policy.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with moderate cognitive impairment in a timely manner. On January 18, 2025, an Activity Assistant was pushing an activity cart when a resident moved in front of it. A Certified Nurse Aide (CNA) standing nearby made a threatening comment, suggesting the Activity Assistant should run over the resident with the cart and kill them because the CNA disliked the resident. This incident was reported to the Activity's Director on the same day, but the Director did not inform the facility administration until January 20, 2025. The facility administration, upon being informed of the incident on January 20, 2025, failed to report the allegation to the Department of Public Health (DPH) within the required two-hour timeframe. Instead, the report was submitted three days later, on January 23, 2025. The Administrator acknowledged a misunderstanding of the reporting process and timing requirements, which led to the delay in reporting the verbal abuse allegation to the appropriate authorities.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff were competent in using Personal Protective Equipment (PPE) for residents requiring transmission-based precautions. Observations revealed that staff did not follow the necessary precautions for residents on Contact Precautions (CP) or Enhanced Barrier Precautions (EBP). For instance, a Certified Nurse Aide (CNA) entered a resident's room without wearing a gown, despite the resident being on EBP due to a Foley catheter. The CNA was unaware of the specific precautions required and did not verify the resident's status with a nurse. Similarly, another CNA and a nurse entered a room with a Contact Precaution sign without using the required PPE, indicating a lack of adherence to infection control protocols. Additionally, the facility did not adequately manage a situation involving a staff member who tested positive for Group A Streptococcal Infection (GAS). The staff member continued to work shifts after testing positive, without being excluded from work until 24 hours after starting antibiotic treatment, as recommended by the CDC. This oversight increased the risk of spreading the infection to other residents and staff members. The Director of Nursing (DON) was unaware that the staff member was working and did not communicate the need for exclusion from work until after the staff member had already worked multiple shifts. The facility's infection control program was further compromised by the lack of clear communication and understanding among staff regarding which residents required precautions. The Unit Manager and Infection Preventionist were unable to accurately identify residents on precautions or the reasons for these precautions. This lack of clarity and adherence to established protocols contributed to the deficiencies observed during the survey.
Delayed Notification of Positive GAS Result
Penalty
Summary
The facility failed to promptly notify the physician of a positive Group A Streptococcal (GAS) test result for a resident, which was reported to the facility on January 19, 2025. The resident, who had a medical history including a stage 4 pressure ulcer, dementia, and a local skin infection, tested positive for GAS in their left shoulder. Despite the facility's policy requiring immediate notification of such results to the physician, the notification was delayed by four days, occurring only on January 22, 2025. As a result of this delay, the necessary contact precautions recommended by the CDC for GAS were not initiated in a timely manner, potentially exposing other residents and staff to the infectious disease. The facility's Infection Preventionist and Director of Nurses both acknowledged the lapse in communication and the failure to implement appropriate precautions and treatments promptly. The Infection Preventionist was not informed of the positive result until the day of the survey, and the Director of Nurses only became aware on the same day, indicating a breakdown in the facility's communication protocols. The Medical Director, who was aware of multiple GAS cases in the facility, was not informed of the delay in reporting the resident's positive result. The facility's policy clearly outlines the steps for handling lab results, including immediate physician notification for abnormal results, which was not followed in this instance. This deficiency highlights a significant lapse in the facility's adherence to its own protocols for managing infectious diseases, thereby compromising resident and staff safety.
Inadequate Infection Control Oversight Following GAS Positive Test
Penalty
Summary
The facility failed to provide appropriate administrative oversight of infection control practices following a positive Group A Streptococcal (GAS) test result for a Certified Nurse Aide (CNA) #1. Despite the facility's awareness of ongoing GAS infections and transmission issues, CNA #1 continued to work on two different resident care units after testing positive for GAS, without adhering to the policy requiring 24 hours of antibiotic therapy before returning to work. This oversight placed residents and staff at risk of contracting and spreading the infectious disease. The facility's policy, aligned with CDC recommendations, mandates that staff who test positive for GAS must be excluded from work until 24 hours after starting effective antimicrobial therapy. However, CNA #1 worked multiple shifts across different units immediately following her positive test result, before completing the required antibiotic treatment period. The Infection Preventionist (IP), new to her role, did not follow up on the test results, and the Director of Nurses (DON) failed to inform CNA #1 or the scheduler about the work exclusion requirement. Interviews revealed that the DON was notified of CNA #1's positive result but did not communicate the necessary work restrictions. CNA #1, unaware of the policy, continued to work after starting antibiotics, as her doctor did not discuss work restrictions with her. The Medical Director, aware of the GAS cases, planned to review infection control policies with the facility to address the issue. The deficiency highlights a lapse in communication and adherence to infection control protocols, leading to potential exposure risks for residents and staff.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, leading to the spread of Group A Streptococcal (GAS) infections among residents and staff. One resident tested positive for GAS, but the laboratory results were not communicated to the physician until four days later, delaying the initiation of appropriate precautions and treatment. Additionally, nursing staff were observed entering and exiting rooms with precaution signs without adhering to the required use of Personal Protective Equipment (PPE), and some staff were unaware of which residents required precautions. Another resident returned from the hospital with sepsis and GAS bacteremia, but the facility's infection control documentation was incomplete, and the resident was not placed on the necessary Contact Precautions. The Infection Preventionist was unaware of the resident's GAS status, and the Director of Nurses acknowledged that the hospital did not always provide complete information. Furthermore, staff were observed not following Enhanced Barrier Precautions (EBP) and Contact Precautions, as they entered rooms without wearing the required PPE, despite signs indicating the need for such precautions. A staff member tested positive for GAS but continued to work on two different units before completing the required 24-hour antibiotic treatment, contrary to facility policy. The Director of Nurses failed to inform the staff member or the scheduler that the staff member could not return to work until after the 24-hour period. This oversight increased the risk of further exposure and transmission of GAS among residents and staff.
Inadequate Staff Competency in Dietary Management for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the appropriate competencies and skill sets necessary for the care of residents, particularly in the area of dietary management for residents with dysphagia. Observations revealed that meals served to residents on modified diets, such as ground or chopped textures, were not prepared according to the prescribed dietary requirements. For instance, residents with orders for ground or chopped diets were served whole or inadequately prepared food items, such as whole penne pasta, intact eggplant parmesan, and unchopped omelets, which were not suitable for their dietary needs. Interviews with staff, including nurses and the Speech Language Pathologist (SLP), indicated a lack of understanding and adherence to the facility's dietary policies. The SLP confirmed that the incorrect preparation of meals posed a safety concern for residents with swallowing difficulties. Furthermore, the Registered Dietitian acknowledged that the kitchen staff was not cutting food into appropriate sizes for residents on chopped diets. The facility's policy required nursing staff to check each food tray for the correct diet before serving, but this was not consistently followed. Additionally, the facility's training and competency evaluation processes were found to be inadequate. Several staff members, including nurses and CNAs, lacked documented competencies in their education files. The Director of Nurses admitted that there was no specific staff member assigned to provide clinical training, and the Administrator acknowledged the absence of a system to ensure staff competency. This lack of structured training and competency evaluation contributed to the deficiencies observed in dietary management and overall resident care.
Failure to Conduct CNA Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to conduct performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and did not provide regular in-service education based on these reviews for three CNAs whose records were reviewed. The facility's policy, last revised in August 2022, mandates regular in-service education and annual performance reviews for nurse aides, with training based on the outcomes of these reviews. However, upon review, the surveyor found that the files for CNAs #1, #5, and #6 lacked performance evaluations. CNA #6, hired in November 2021, had no file or information regarding education or performance evaluations. CNA #1, hired in April 2023, and CNA #5, hired in October 2019, also had no performance evaluations in their files. The Administrator confirmed that there was no process in place for conducting annual performance reviews or for basing in-service training on these reviews, and no staff member was assigned to perform these evaluations.
Deficiency in CNA Training Documentation and Tracking
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required 12 hours of annual training, which must include dementia care and abuse prevention. This deficiency was identified through staff interviews and record reviews, revealing that none of the three CNA education files reviewed met the training requirements. The facility's policy mandates regular in-service education and performance reviews to ensure the continuing competency of nurse aides, but these were not adequately documented or tracked. The Human Resources Coordinator was unable to provide an education file for one CNA hired in November 2021, and the files for the other two CNAs lacked sufficient documentation of completed training hours. The Administrator acknowledged that an education fair was held, but there was no process in place to track the hours or ensure the training was based on performance reviews. Both the Assistant Director of Nurses and the Director of Nurses, who started working at the facility in 2024, admitted they had not been tracking CNA in-service hours since their arrival.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that three residents received timely visits from their physician or nurse practitioner as required by regulations. Resident #78 was not seen by a physician or nurse practitioner every 60 days, with a gap of 106 days between visits and 151 days between physician visits. The Director of Nurses (DON) acknowledged the issue, and the Administrator confirmed the lack of additional visits. Resident #66 was not seen every 30 days for the first 90 days of admission, with a 91-day gap without a visit. The DON confirmed the oversight, and no additional documentation was provided to the survey team. Resident #43 experienced a 104-day gap between visits and had not been seen by a physician for 138 days. The DON stated that the resident should have been seen every 30 days for the first 90 days and every 60 days thereafter, with alternating visits between the physician and nurse practitioner. The survey team did not receive any further evidence of visits for Resident #43. These deficiencies indicate a failure to adhere to the facility's policy and OBRA regulations regarding the frequency and documentation of physician visits.
Deficiency in Food and Nutrition Services Staffing and Competency
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, the facility did not ensure that support staff with the necessary competencies and skills were available to provide meals that met the residents' needs. Observations revealed that meals were not prepared according to the required dietary textures, with ground-textured meals, chopped meals, and regular-textured meals containing whole foods without distinguishable differences. Additionally, meal tickets were not followed accurately, as evidenced by a resident receiving incorrect meal portions and textures. The facility's policies on food and nutrition services, tray identification, and kitchen weights and measures were not adhered to, as dietary staff failed to inspect food trays to ensure correct meals were provided. The Food Service Director (FSD) was unaware of the kitchen's inconsistency in preparing and serving diets and food textures consistent with facility policy, physician's orders, and the Dietitian's and Speech Language Pathologist's (SLP) recommendations. The SLP noted that the kitchen had been slowly implementing diet and food texture changes, but these changes were not consistently maintained. Furthermore, the facility did not provide documentation that dietary competencies were conducted on all dietary personnel. The FSD admitted to not maintaining documentation of job-related competencies for dietary staff, and any education or in-service provided was verbal without documentation. A review of five random dietary employee files showed no competency documentation. The SLP also indicated that therapeutic diets or diet textures were not included in the orientation program, and only two dietary staff members attended an in-service on dysphagia diets in June 2024.
Failure to Provide Appropriate Modified Texture Diets
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet the individual needs of residents requiring modified texture diets. Specifically, the facility did not provide meals in the appropriate ground or chopped texture as ordered by physicians for several residents. This deficiency was observed during a survey where meals intended for ground-textured diets were served with whole penne pasta and large pieces of eggplant parmesan, contrary to the dietary requirements. Residents with specific dietary needs, such as those with dysphagia, were not provided with meals that matched their prescribed diet textures. For instance, a resident with a ground texture diet order was served a meal with whole penne pasta and large pieces of eggplant, which was not suitable given the resident's edentulous condition. Another resident, who was supposed to receive a chopped diet, was served whole omelets and unchopped vegetables, which did not align with the dietary orders. The facility's policies on therapeutic diets and food and nutrition services were not adhered to, as evidenced by the incorrect meal preparations and servings. Staff members, including dietary staff and unit managers, were observed to lack understanding of the appropriate diet textures, leading to the provision of meals that posed potential safety concerns for residents with swallowing difficulties. The Speech Language Pathologist and Registered Dietitian both noted discrepancies in meal preparation, indicating a systemic issue in the facility's dietary service processes.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary and safe condition, as observed by the surveyor. The kitchen had several areas of concern, including gaps between baseboard molding and floor tiles, buildup of crumbs and debris, dust and debris underneath the range, and black splotchy growth on walls in the dish room. Additionally, there was black, crumbling, and slimy grout in the dish room, crumbled drywall around an electrical outlet, and peeling and stained ceiling tiles with food splatter. The metal ceiling grids had chipping paint, and fans used to circulate air had severe dust buildup. The surveyor also noted issues in the dry storage room and walk-in refrigerator. The dry storage room had black splotchy growth around its perimeter and a mouse dropping on a dusty wall lip above the shelves. The walk-in refrigerator had shelves soiled with tan-colored, fluffy buildup, condenser fans with thick gray buildup, and interior walls with light-colored fluffy buildup. The milk chest had spilled milk and a foul odor of spoiled milk, which worsened over the days of observation. Interviews with the Food Service Director (FSD) and dietary staff revealed a lack of awareness and adherence to cleaning schedules. The FSD acknowledged the need for better cleaning and maintenance, particularly regarding the ceiling tiles, metal grids, and fans. The Director of Maintenance (DOM) also recognized the need for repairs and cleaning in various areas. The Director of Nursing (DON) expressed expectations for the kitchen to operate under clean and sanitary conditions, highlighting the importance of maintaining uncompromised kitchen areas to prevent contamination and foodborne illness.
Failure to Administer Pneumonia Vaccines to Consenting Residents
Penalty
Summary
The facility failed to administer pneumonia vaccines to 12 residents who had signed consents to receive the vaccine. A review of a random sample of 20 residents who consented to receive the pneumonia vaccine revealed that 12 residents had not been given the vaccine by the specified date. The facility's policy, revised in August 2024, outlines the recommended vaccines and vaccination schedule, including the Pneumococcal Conjugate Vaccine (PCV13) and the Pneumococcal Polysaccharide Vaccine (PPSV23), and emphasizes the importance of routine screening, vaccination programs, and accurate documentation. During an interview, the Infection Preventionist (IP) acknowledged that the residents who had consented to receive the pneumonia vaccine had not yet received it. The IP mentioned that the facility had just ordered the pneumonia vaccine and planned to administer it once received. The IP, who had recently assumed the role, expressed an understanding of the importance of immunizing and protecting residents against pneumonia, especially during the cold, flu, and pneumonia season. The report highlights a lapse in the facility's immunization program, as the vaccines were not administered in a timely manner despite the residents' consent.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the pain management needs of a resident diagnosed with spinal stenosis, pain, and abnormal posture. Despite the resident being cognitively intact and receiving scheduled pain medication and non-medication interventions, the care plan did not include a specific plan for managing the resident's pain. The Minimum Data Set (MDS) assessment indicated that the resident experienced occasional pain that limited daily activities, yet this was not reflected in a comprehensive care plan. Interviews with the resident, unit manager, MDS coordinator, and Director of Nursing (DON) revealed a lack of documentation and implementation of a pain care plan. The resident expressed awareness of taking medications for pain but was unaware of any specific care plan or interventions available. The unit manager acknowledged the need for a pain care plan and mentioned ongoing therapy and medication management. The MDS coordinator confirmed that a care plan should have been developed based on the resident's assessment, and the DON expected a pain care plan to be in place due to the resident's diagnoses, but noted that interventions were not documented in a care plan.
Medication Transcription Error Leads to Overmedication
Penalty
Summary
The facility failed to ensure that a resident was provided care in accordance with professional standards of practice, specifically in the transcription and administration of medication orders. Resident #42, who was admitted with diagnoses including diabetes mellitus and end-stage renal disease, was prescribed levofloxacin for pneumonia. The physician's orders specified an alternating dosage schedule, but due to an incorrect transcription, the resident received 14 additional doses of the antibiotic. The error was identified through a review of the resident's Medication Administration Record, which showed that the resident received 17 doses of levofloxacin over a period when only three doses were prescribed. Interviews with the Unit Manager and the Director of Nurses confirmed the transcription error and highlighted the importance of following physician's orders accurately, including implementing correct stop dates. This deficiency was noted under F757, indicating a failure to meet professional standards of quality care.
Failure to Perform Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure that wound treatments were conducted according to physician's orders for a resident with peripheral vascular disease and arterial wounds on the right foot. The resident, who was admitted in October 2024, had specific treatment orders for wounds on the right dorsal and lateral foot, which included cleansing with normal saline, applying Santyl, Calcium Alginate, and covering with ABD pad and Kerlix. However, observations on multiple occasions revealed that the resident's right foot wounds were not covered with the prescribed dressings, indicating a failure to perform the ordered treatments. Interviews with the nursing staff revealed a lack of awareness and execution of the prescribed treatments. Nurse #4, who was responsible for the resident's care on the observed days, admitted to only applying skin prep and was unaware of the additional treatment orders involving Santyl and Calcium Alginate. Despite documentation in the Treatment Administration Record indicating that treatments were completed, the nurse could not confirm their execution, and the Director of Nurses acknowledged that treatments should be completed as ordered and accurately documented.
Failure to Implement Pain Management Recommendations
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic low back pain, as per the recommendations of a consulting physiatrist. The resident, who had moderate cognitive impairment, reported daily pain that affected sleep and daily activities. Despite the physiatrist's recommendation to increase the resident's gabapentin dosage from 100 mg to 300 mg at bedtime, this change was not implemented. The recommendation was noted in the facility's communication log and approved by a nurse practitioner, but the order was not carried out, leaving the resident on the lower dosage. Interviews with facility staff, including a nurse, a nurse practitioner, and a unit manager, confirmed that the recommendation was approved but not executed. The Director of Nurses acknowledged that once a consultant's recommendations are approved, they should be implemented. The failure to increase the medication dosage as recommended resulted in the resident continuing to experience unmanaged pain, which was contrary to professional standards of practice and the resident's care plan.
Failure to Ensure Safe Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease who was dependent on renal dialysis. The facility did not develop and implement a comprehensive dialysis care plan, which included individualized interventions and monitoring of the dialysis access site. There was no evidence of communication with the contracted dialysis facility for seven treatments, and the facility did not obtain physician's orders for monitoring, cleaning, and dressing the access site until 19 days after the resident's admission. Interviews revealed that there was no written communication between the facility and the dialysis center regarding the resident's treatments, medications, labs, or advanced directives. The resident was unaware of how the facility communicated with the dialysis center, and there was no documentation of pre- and post-dialysis weights. The Unit Manager acknowledged the lack of communication and care planning, and the Director of Nurses confirmed that the facility's process should include a binder for communication and collaboration of care before and after dialysis, which was not in place.
Failure to Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and eliminate triggers for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD), which could potentially lead to re-traumatization. The resident, who was moderately cognitively impaired, had a history of marital and childhood abuse. Despite having a care plan that included interventions for PTSD, such as providing a calm environment and discussing coping strategies, the facility did not identify or document any specific PTSD triggers for the resident. This oversight occurred even though the resident expressed feeling scared when another resident wandered into their room. Interviews with facility staff revealed that the social worker responsible for identifying PTSD triggers did not discuss potential triggers with the resident's representative, as the representative preferred discussions to occur in the resident's presence. The unit manager and the Director of Nurses were aware of the resident's PTSD diagnosis but were not informed of any specific triggers. The resident's representative confirmed that the facility acknowledged the PTSD diagnosis but did not inquire about potential triggers, despite the resident's distress over another resident's behavior.
Failure to Document Medication Regimen Review Reports
Penalty
Summary
The facility failed to ensure that the monthly medication regimen review (MRR) reports for two residents were included in the medical records or readily available for review. Resident #51, admitted with diagnoses including depression, heart failure, and dementia with behavioral disturbance, had MRRs completed by the Consultant Pharmacist on three occasions. However, the medical record did not include the Consultant Pharmacist reports indicating the recommendations made and the Physician's response. Interviews revealed that the pharmacy recommendation reports were stored in the Director of Nurses' (DON) office and not in the residents' charts. The DON admitted to not having the reports for the specified dates. Similarly, Resident #68, admitted with diagnoses including depression and heart failure, had an MRR completed, but the medical record failed to include the Consultant Pharmacist report and the Physician's response. The process described by the DON involved receiving the reports via email, distributing them to each unit for physician review, and then storing them in her office. However, the DON was unable to locate the report for Resident #68. This indicates a failure in the facility's process to ensure that MRR reports are properly documented and accessible in the residents' medical records.
Excessive Administration of Antibiotic Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs and was not used for an excessive duration. Specifically, the facility did not adhere to the physician's order for administering levofloxacin, an antibiotic, to a resident diagnosed with pneumonia. The physician's order specified that the resident should receive levofloxacin for only three doses, but the resident received a total of 17 doses over a period of time, resulting in an additional 14 administrations. The error was attributed to an incorrect transcription of the order, as confirmed by the Unit Manager during an interview. The Director of Nurses acknowledged that physician's orders should be followed accurately, and appropriate stop dates should be implemented when transcribing orders. The resident involved was admitted to the facility with diagnoses including diabetes mellitus and end-stage renal disease. At the time of the deficiency, the resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15, and had been receiving antibiotics as part of their care plan for pneumonia.
Failure to Limit PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not limit the use of an as-needed antipsychotic medication to 14 days or provide a documented clinical rationale and duration for extending its use beyond 14 days. The facility's policy on antipsychotic medication use, dated July 2022, requires that PRN orders for antipsychotic medications not be renewed beyond 14 days unless the healthcare practitioner evaluates the resident for the appropriateness of the medication. The resident in question was admitted to the facility with diagnoses of depression and dementia with behavioral disturbance. The Minimum Data Set assessment indicated that the resident was moderately cognitively impaired. The resident had a physician's order for Risperdal, an antipsychotic medication, to be given as needed for agitation. However, the medical record did not show that the Risperdal order was re-evaluated after 14 days, despite the resident receiving the medication. During an interview, the Director of Nursing confirmed the expectation that as-needed antipsychotic orders should be written for a 14-day duration and reevaluated by the prescriber.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by Nurse #3 committing three errors out of 27 opportunities, resulting in an 11.11% error rate. For Resident #97, Nurse #3 omitted the administration of famotidine and folic acid, marking them as unavailable without notifying the provider. The nurse indicated that if a medication was not available, especially if it was a vitamin, she would mark it as unavailable and reorder it without further action. The Unit Manager and the Director of Nurses (DON) later confirmed that the physician should have been notified to adjust the treatment plan if necessary, and this notification should have been documented. Additionally, Nurse #3 administered a normal saline flush to Resident #256's intravenous catheter without a physician's order. The nurse admitted to performing the flush out of habit, without checking for an order. The DON stated that all medications and treatments require a physician's order, and Nurse #3 should have obtained one before administering the flush. These actions contributed to the facility's failure to adhere to safe medication administration practices, as outlined in both the Lippincott Nursing Procedures and the facility's own medication administration policy.
Deficiency in Drug Storage and Access Control
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles. Specifically, the facility did not store all drugs and biologicals in locked compartments under proper temperature controls, and did not restrict access to authorized personnel only. The facility's policy required that the refrigerator or freezer storing vaccinations be checked at least twice a day, but the East Unit medication refrigerator's temperature was recorded only once per day from October 1, 2024, to November 20, 2024. This was confirmed during interviews with Nurse #5, Unit Manager #2, and the Director of Nurses (DON), who acknowledged that the temperature should be monitored twice daily when vaccines are stored. Additionally, the facility failed to provide separately locked, permanently affixed compartments for controlled drugs. During an observation, a plastic container with Lorazepam, a Schedule IV controlled substance, was found in the medication room refrigerator, which was not permanently affixed and could be easily removed. Both nurses on the unit had access to the controlled substances, despite the medication bottles being assigned to only one nurse. The DON confirmed that controlled substance containers should be permanently affixed inside the refrigerator and that only the nurse responsible for the patient should have access to their controlled substances.
Unsecured Handrail Poses Safety Hazard
Penalty
Summary
The facility failed to ensure that the handrail in the corridor of the [NAME] Unit was securely attached to the wall, posing a potential safety hazard to residents. The maintenance log indicated that the handrail outside of a specific room was reported as broken between 10/16/24 and 10/25/24, but there was no indication of completion or acknowledgment of the repair. During an initial tour on 11/19/24, the surveyor observed the handrail was loose and not securely attached, with areas of broken plaster and holes. This issue persisted during a follow-up environmental tour on 11/20/24, where multiple residents were observed sitting near the broken handrail. Interviews conducted during the survey revealed that the Maintenance Director was the sole person in his department and was overwhelmed with tasks, which limited his ability to conduct frequent rounds. He acknowledged that all resident areas should be safe and in good repair. A resident reported that the handrail had been broken since moving into their new room weeks ago, and noted that the other side of the handrail was also broken, making it unsafe to apply pressure. The Administrator expressed that she would expect such issues to be identified and repaired, acknowledging the risk posed by the unsecured handrail.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's Health Care Agent was provided with necessary information and written informed consent was obtained prior to the administration of psychotropic medications. The resident, diagnosed with dementia and other conditions, had an activated Health Care Proxy indicating incapacity to make rational evaluations regarding treatment. Despite this, the facility administered Amitriptyline HCL and Quetiapine Fumarate without obtaining the required informed consent from the Health Care Agent. The facility's policy and Massachusetts regulations require informed consent for psychotropic medications, including documentation of the treatment's nature, risks, and benefits. However, the facility did not provide the Health Care Agent with information about the medications or obtain signed consent. Interviews with the Health Care Agent and the facility's Administrator confirmed the absence of documentation supporting informed consent for the administered medications.
Failure to Suspend Staff and Conduct Background Checks Following Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy following an allegation of sexual abuse involving a resident. The policy required that any staff member implicated in a potential abuse incident be immediately removed from resident areas and suspended pending investigation. However, after a family member reported the alleged abuse, the facility did not suspend the two CNAs who fit the description of the accused staff member. Both CNAs continued to work double shifts during the investigation period, contrary to the facility's policy. The investigation into the allegation was mishandled due to a miscommunication between the Director of Nurses (DON) and the Assistant Director of Nurses (ADON). The DON assumed the ADON was conducting the investigation, while the ADON believed the DON was responsible. This miscommunication resulted in a delay in the investigation process, and the implicated CNAs were not suspended as required by the facility's policy. The internal investigation was closed without suspending the CNAs, and the police were involved after the fact. Additionally, the facility did not conduct the required Massachusetts Nurse Aide Registry (NAR) and Criminal Offender Record Information (CORI) checks for the CNAs prior to their employment. The employee files for both CNAs lacked documentation to support that these checks were performed, which is a violation of the facility's hiring policy. The administrator confirmed the absence of these checks, which are crucial for ensuring that staff members do not have a history of abuse or criminal activity.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The incident involved a resident who had been admitted to the facility in May 2022, with diagnoses including fractures, pulmonary embolism, and dementia. On May 6, 2024, the resident's family member reported concerns of sexual abuse by a male staff member to the Director of Nurses (DON) and Assistant Director of Nurses (ADON). However, the report was not submitted to the DPH until the following day, May 7, 2024. The delay in reporting was attributed to a miscommunication between the DON and ADON regarding who was responsible for investigating the allegation. The DON assumed the ADON was handling the investigation, while the ADON believed the DON was responsible. This miscommunication resulted in the failure to report the allegation within the mandated timeframe. The facility's policy requires immediate reporting of suspected abuse to the state agency, which was not adhered to in this case.
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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