Melrose Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Melrose, Massachusetts.
- Location
- 40 Martin Street, Melrose, Massachusetts 02176
- CMS Provider Number
- 225329
- Inspections on file
- 14
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Melrose Healthcare during CMS and state inspections, most recent first.
The facility failed to develop comprehensive care plans for two residents, one with legal blindness and severe cognitive impairment, lacking plans for vision, communication, and fall risk, and another with a pacemaker, missing a care plan for its management. Despite policy requirements and triggered assessments, these care plans were not implemented, as confirmed by staff.
The facility failed to provide residents with private access to telephones, requiring them to use the phone at the nurses' station where conversations could be overheard. Previously available portable phones for private calls were no longer accessible, and staff were unaware of the option to use a private office for calls.
The facility failed to secure and properly label medications, with medication carts left unlocked and unattended, and several inhalers and an insulin pen found opened and undated. Nursing staff acknowledged the need for secure storage, and the DON confirmed the requirement for proper labeling and storage.
The facility failed to adhere to food safety standards, with improperly stored and undated food items found in the kitchen, and mold and standing water observed in a basement refrigerator. Dented cans were improperly stored, indicating a lapse in following procedures for handling damaged goods.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in care documentation. A resident with paralysis was incorrectly documented as being transferred out of bed, while another resident's wound dressing changes were falsely recorded as completed. Additionally, a third resident's skin assessments contained inaccuracies, including a non-existent stage IV pressure ulcer. These issues were confirmed by staff and the DON.
The facility failed to obtain informed consent for psychotropic medications for two residents with severe cognitive impairments. One resident was prescribed Mirtazapine without a signed consent form, and another received Ativan without documented consent. Both the DON and a nurse confirmed that consent should have been obtained prior to administration.
The facility failed to maintain valid guardianships and health care proxies for two residents. One resident's guardianship for anti-psychotic medication was not reviewed as required, while another resident's health care proxy was unreachable, and no new representative was established. Both residents had moderate cognitive impairment, and the facility did not pursue necessary guardianship actions.
A resident with a history of stroke and paralysis was found confined to bed in a dark room without a means to get out, indicating involuntary seclusion. Despite expressing a desire to get out of bed, the resident was not provided with a chair or assistance, and staff were unaware of the resident's mobility needs. The care plan lacked documentation of the resident's preferences, and physical therapy was insufficient, highlighting a failure in communication and coordination among staff.
A resident with a history of stroke and moderate cognitive impairment was found with a pillow under the fitted sheet of their bed, restricting movement and acting as a restraint. The pillow was placed to prevent the resident from getting out of bed due to high fall risk, but no restraint assessment was documented. The DON confirmed this was against facility policy.
A resident with peripheral vascular disease and obesity did not receive daily wound dressing changes as ordered by the physician for five days. Despite records indicating compliance, observations and interviews revealed the dressing was unchanged, and there was no documentation of refusal. The DON confirmed the need for adherence to the physician's order and proper documentation.
Two residents in an LTC facility were not provided with necessary meal assistance, leading to deficiencies in care. One resident with moderate cognitive impairment was left unsupervised during meals, contrary to their care plan. Another resident with dysphagia and a history of stroke was observed eating in an unsafe position without supervision, despite requiring assistance. Staff interviews confirmed the need for supervision, which was not provided.
The facility failed to provide an adequate activity program for three residents, leading to a deficiency in meeting their needs. A resident with moderate cognitive impairment was observed spending entire shifts in bed without any activity materials or entertainment. Another resident with Alzheimer's expressed boredom and a desire for activities but was not observed participating in any. A third resident with severe cognitive impairment was also not engaged in activities, despite preferences for music and religious activities. The Activities Director cited being understaffed as a reason for the lack of engagement.
A resident with severe cognitive impairment and a history of Wernicke's encephalopathy and other conditions expressed a desire for vision services. Despite recommendations for cataract surgery and a referral to ophthalmology, the facility failed to make an appointment or contact the resident's health care agent for approval, as revealed in staff interviews and record reviews.
A resident with COPD did not receive oxygen as per physician's orders in a facility. Despite having a continuous oxygen order, the resident was observed multiple times without oxygen, and no portable concentrator was present. The facility's records showed no recent oxygen saturation assessments, and staff interviews confirmed the oversight.
A resident with end-stage renal disease did not have a care plan for monitoring their AV fistula, and the facility lacked an emergency kit at the bedside as required. Staff were unaware of the resident's dialysis access method, and observations confirmed the absence of the emergency kit, despite physician's orders and care plan requirements.
A facility failed to implement a pharmacist's recommendation for a resident's PRN Ativan order, which should have been limited to 14 days. Despite the physician agreeing to the recommendation, the nursing staff did not update the orders, leading to a deficiency. The resident had severe cognitive impairment and multiple diagnoses, including end-stage renal disease.
A facility failed to limit a PRN Ativan order to 14 days for a resident with severe cognitive impairment and multiple diagnoses, including anxiety. The physician's order lacked a stop date, and the medication was administered without the required limitation. The DON acknowledged the expectation for a 14-day stop date and re-evaluation.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #47, who was admitted with diagnoses including legal blindness, anxiety, dementia, and depression, did not have care plans for vision, communication, or fall risk, despite these areas being triggered in the Care Area Assessment (CAA) of the Minimum Data Set (MDS). The resident was observed to have severe cognitive impairment and required assistance for all tasks, yet the care plans did not reflect these needs. The MDS nurse confirmed that care plans should have been developed for the triggered areas, but they were not. Resident #53, admitted with a pacemaker and other medical conditions, did not have a care plan addressing the pacemaker, despite the presence of a Medtronic device used for monitoring. The facility's policy requires documentation of specific details about the pacemaker and monitoring procedures, but these were absent from the resident's medical record. The Director of Nurses and a nurse acknowledged the lack of a care plan and orders for pacemaker checks, despite the resident's awareness of having a pacemaker and the device being observed in use.
Lack of Privacy in Resident Phone Calls
Penalty
Summary
The facility failed to ensure that residents on all three units had access to a telephone for private conversations. During a Resident Group Interview, residents reported that they could only use the phone at the nurses' station, where their conversations could be overheard by others. Previously, the facility had a portable phone that allowed residents to make calls in private, but it was no longer available. This issue was observed by surveyors when a resident was seen making a call at the nurses' station, with staff and other residents present who could overhear the conversation. Interviews with staff, including a CNA and the Activity Director, confirmed that residents were required to use the phone at the nurses' station due to the absence of the previously available cordless phone. The Director of Nursing mentioned that there was an office available for private calls but was unaware that staff were not assisting residents to use this space for private conversations. This lack of privacy in communication methods was consistent across all units, as reported by both residents and staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and labeled according to professional standards. On multiple occasions, medication carts on two of the four units were observed to be left unlocked and unattended. Specifically, on the second floor, medication carts were found unlocked and out of the line of vision of the nursing staff. Nurses acknowledged that medication carts should be locked when unattended, yet this practice was not consistently followed. The Director of Nursing confirmed that medication carts should always be locked when not in use. Additionally, the facility did not adhere to proper labeling and storage guidelines for medications. During a medication administration pass, an unlabeled and undated inhaler was found in a vital sign machine in the hallway, and it was unclear to whom it belonged. The inhaler was left on top of a medication cart, unattended and out of the nurse's line of vision. Furthermore, several inhalers and an insulin pen in the A Unit Medication Cart were found opened and undated, contrary to the facility's policy and manufacturer's guidelines. The Director of Nursing stated that inhalers should be labeled with the resident's name, the date opened, and stored in the manufacturer's box, which was not done in these instances.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial tour of the kitchen, several food items were found improperly stored, including an opened and undated container of cool whip, a container of coleslaw with a discard date that had passed, a container of tuna salad with an expired discard date, undated cold cuts, an undated prepared salad, and undated slices of pizza wrapped in tin foil. These observations indicate a lack of adherence to the facility's policy on food and supply storage, which requires discarding food that exceeds its use-by date or is incorrectly stored. Additionally, during an observation in the basement food storage area, a strong musty odor was detected, and mold was observed along with standing water in a chest refrigerator containing multiple cases of milk. Two dented cans were also found in the basement storage area. The Regional Food Service Director acknowledged that staff should notify management if the refrigerator needs maintenance and that dented cans should be set aside for return to the vendor. However, two significantly dented cans of chili con carne were found stored on the can rack in the kitchen, indicating a failure to follow the procedure for handling damaged goods.
Inaccurate Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. For one resident with a history of stroke and paralysis, the facility inaccurately documented that the resident had been transferred out of bed, despite observations and staff interviews indicating the resident remained in bed for safety reasons. This discrepancy was confirmed by the Director of Nursing, who acknowledged that the CNAs should not have documented an activity that did not occur. Another resident, diagnosed with peripheral vascular disease and obesity, experienced a failure in wound care documentation. The resident's physician ordered daily dressing changes for a foot wound, but the dressing was not changed for five consecutive days, despite being documented as completed. This was confirmed by a nurse and the Director of Nursing, who both stated that the dressing changes should have been performed as ordered and accurately documented. The third resident, with end-stage renal disease and a left leg amputation, had inconsistencies in skin assessment documentation. The resident's records showed conflicting information about the presence and severity of pressure ulcers, with one report inaccurately indicating a stage IV pressure ulcer that was not present. The Director of Nursing confirmed the inaccuracies in the skin evaluations, highlighting a failure to document the resident's skin condition accurately.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, leading to a deficiency in compliance with their own policy. Resident #47, who was admitted with severe cognitive impairment and dependent on staff for all care, was prescribed Mirtazapine for increased appetite. However, the medical record did not contain a signed consent form for this medication. The Director of Nursing confirmed that consent should have been obtained prior to administration. Similarly, Resident #76, who was also severely cognitively impaired and admitted with conditions including end-stage renal disease and anxiety, was prescribed Ativan. The resident's medical record lacked a signed consent form for the administration of Ativan, despite the medication being administered as ordered. Both the Director of Nursing and a nurse acknowledged that consent should have been obtained before administering psychotropic medications.
Failure to Maintain Valid Guardianships and Health Care Proxies
Penalty
Summary
The facility failed to ensure that advanced directives related to guardianships were valid and in place for two residents. For one resident, the facility did not review and renew an established guardianship for authorizing treatment with anti-psychotic medication as required by a court order. The resident, who was admitted with diagnoses including schizoaffective disorder and bipolar disorder, had moderate cognitive impairment. The guardianship was supposed to be reviewed by a specific date, but the clinical record did not show that this was done, and the social worker confirmed the oversight during an interview. For another resident, the facility did not establish a new health care agent or representative when the current health care proxy became unreachable. This resident, admitted with conditions such as Wernicke's encephalopathy and chronic obstructive pulmonary disease, also had moderate cognitive impairment. Attempts to contact the health care agent were unsuccessful, and a certified letter was sent without further follow-up. The Director of Nursing acknowledged the difficulty in reaching the health care agent and the lack of other family or friends involved, indicating that guardianship should have been pursued but was not prior to the surveyor's inquiry.
Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion, as evidenced by the case of Resident #31. The resident, who was admitted with a history of stroke and paralysis, was observed lying in bed in a dark room with a closed door on multiple occasions. A pillow was placed under the fitted sheet on the left side of the mattress, preventing the resident from moving his/her legs to that side of the bed. The resident expressed a desire to get out of bed but was unable to do so due to the lack of a chair in the room and the inability to move the pillow. The resident's care plan indicated a need for assistance with transfers and locomotion, but there was no documentation of the resident's preference to stay in bed or refusal to get out of bed. Physical therapy notes showed that the resident only received two therapy sessions, and there was no indication of attempts to assist the resident with sitting or transferring out of bed. Interviews with staff revealed a lack of awareness and action regarding the resident's mobility needs, with some staff believing it was safer for the resident to remain in bed due to fall risks. The Director of Nursing and other staff members acknowledged that residents should be asked daily if they wish to get out of bed and should be provided with a means to do so. However, there was a clear lack of communication and coordination between nursing and therapy staff, resulting in the resident being effectively confined to bed without proper assessment or provision of mobility aids.
Improper Use of Restraint with Pillow Under Fitted Sheet
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the use of a pillow placed under a fitted sheet on the resident's bed. This setup restricted the resident's ability to move his or her legs to one side of the bed, effectively acting as a restraint. The resident, who had a history of stroke with paralysis on the right side and required maximal assistance for bed mobility, was unable to remove the pillow due to moderate cognitive impairment and physical limitations. The resident expressed unawareness of the pillow's purpose and an inability to remove it. Observations revealed that the pillow was placed under the fitted sheet to prevent the resident from getting out of bed, as confirmed by a CNA who stated that the resident was a high fall risk. The facility's policy on restraints indicated that restraints should only be used for medical symptoms and not for staff convenience or fall prevention. However, the resident's medical record did not show any assessment for the use of restraints, and the Director of Nursing acknowledged that the pillow constituted a restraint, which was against the facility's policy.
Failure to Follow Physician's Order for Wound Dressing
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident with peripheral vascular disease and obesity, who was admitted in December 2022. The resident had a physician's order for a daily wound dressing on an open lesion on the right foot, which was not followed for five consecutive days. Despite the treatment administration record indicating that the dressing was changed daily, observations and interviews revealed that the dressing had not been changed since 3/27/24, contradicting the documented records. Interviews with the nursing staff and the wound physician confirmed that the dressing was not changed as ordered, and there was no documentation of the resident refusing the dressing changes. The Director of Nursing acknowledged that the dressing should have been changed according to the physician's order and that any refusal or failure to change the dressing should have been documented properly. The lack of communication and documentation regarding the dressing changes led to the deficiency in care for the resident.
Failure to Provide Meal Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents, leading to deficiencies in care. Resident #379, who has moderate cognitive impairment and requires supervision during meals, was observed eating alone in their room on multiple occasions. Despite the care plan indicating the need for supervision and assistance as needed, the resident was left unsupervised, with food observed on their chest during one instance. Interviews with staff confirmed that the resident requires supervision while eating, which was not provided as per the care plan. Similarly, Resident #30, who is cognitively intact but has a history of stroke, dysphagia, and paraplegia, was observed eating in an unsafe position without supervision. The resident's care plan indicated a need for varying levels of assistance, including supervision due to swallowing difficulties. Despite this, the resident was left alone during meals, with staff acknowledging the need for supervision due to frequent coughing while eating. The Director of Nursing and CNAs confirmed that supervision was expected but not provided, leading to a failure in adhering to the care plan.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for three residents, leading to a deficiency in meeting their physical, mental, and psychosocial needs. Resident #31, who was admitted with a stroke and moderate cognitive impairment, was observed spending entire shifts in bed without any activity materials or entertainment like television or music. Despite having preferences for music, reading, and spiritual activities, there was no activity care plan developed for this resident, and no documentation of participation in activities since admission. Resident #38, diagnosed with Alzheimer's Disease and depression, expressed boredom and a desire for activities such as card games and music. However, the resident was not observed participating in any activities during the survey period, and there was no radio in the room despite the resident's preference for music. The activity care plan for this resident was outdated, and there was no documentation of activity participation since March 2024. Resident #47, with severe cognitive impairment, was also not observed participating in activities during the survey period. The resident's activity assessment indicated a preference for music and religious activities, but there was no radio available, and the staff reportedly hid the resident's radio. The activity care plan included interventions for one-on-one contacts and structured programs, but the resident had only participated in activities twice since March 2024. The Activities Director cited being understaffed and pulled away for other duties as reasons for the lack of activity engagement.
Failure to Follow Up on Ophthalmology Referral for Resident
Penalty
Summary
The facility failed to follow up on a referral for ophthalmology services for a resident with severe cognitive impairment. The resident, admitted in February 2016, has diagnoses including Wernicke's encephalopathy, chronic obstructive pulmonary disease, and alcohol dependence. The resident expressed a desire to see an eye doctor and obtain glasses. Optometry notes from November 2023 and March 2024 indicated the resident was a glaucoma suspect and had cataracts, with a recommendation for cataract surgery and a referral to ophthalmology. However, the clinical record did not show that a referral was made or an appointment scheduled, nor was there evidence that the recommendation was reviewed with the resident's activated health care agent. Interviews with facility staff revealed that the eye appointment was not made, and the facility had been unable to contact the resident's health care agent for many months. A certified letter was sent to the health care agent in January 2024 regarding vaccination consent, but there was no documentation of attempts to reach the agent about vision services. The Director of Nursing acknowledged the need for approval from the health care proxy to proceed with the referral, highlighting a communication gap in addressing the resident's vision care needs.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who was cognitively intact, had a physician's order for continuous oxygen administration to maintain oxygen saturation levels above 90%. However, observations by the surveyor on multiple occasions revealed that the resident was not receiving oxygen, and there was no portable oxygen concentrator present in the room. The facility's records indicated that oxygen was supposedly administered, but there was no evidence of oxygen saturation assessments being conducted since the last recorded measurement on March 27, 2024. Interviews with nursing staff and the Director of Nursing confirmed the oversight. Nurse #7 admitted to not assessing the resident's oxygen saturation during her shift and acknowledged the continuous nature of the oxygen order. The Director of Nursing also confirmed that the oxygen order was continuous and expected that oxygen saturation should be assessed every shift. Despite these expectations, the facility's documentation and observations indicated a failure to adhere to the physician's orders and the facility's own policy on oxygen administration.
Failure to Provide Appropriate Dialysis Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required hemodialysis. The resident, who was cognitively intact, had an AV fistula in the left arm for dialysis access, but the facility did not have a care plan in place for monitoring this site. The resident's active physician's orders did not include instructions to monitor the AV fistula, and the nursing progress notes from February to April did not document any monitoring of the site. Interviews with nursing staff revealed a lack of awareness regarding the resident's dialysis access method, with conflicting information about whether the resident received dialysis through a chest catheter or the AV fistula. Additionally, the facility failed to maintain an emergency kit at the resident's bedside, as required by the physician's orders and the dialysis care plan. Observations on multiple occasions confirmed the absence of the emergency kit, which was supposed to be available in case of bleeding from the dialysis access site. Interviews with nursing staff and the Director of Nursing confirmed that the emergency kit was missing, despite the expectation that it should be present in the resident's room.
Failure to Implement Pharmacist's Recommendations for PRN Medication
Penalty
Summary
The facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for a resident with end-stage renal disease, anxiety, and a left leg above-the-knee amputation. The resident was assessed as severely cognitively impaired and had a physician's order for Ativan, a psychotropic medication, to be administered as needed. The pharmacist recommended that the PRN order for Ativan should be limited to 14 days, and if extended, the prescribing practitioner must document the rationale and specify a stop date. The physician agreed with this recommendation, but the nursing staff did not follow through with updating the physician's orders to reflect the pharmacist's recommendations. The deficiency was further highlighted by a practitioner progress note indicating that the Ativan order should have a 14-day stop date, which was not implemented. During an interview, the Director of Nursing expressed that she expected the recommendations from the pharmacist's MRR to be followed. This oversight in updating the physician's orders after the pharmacist's recommendations and the practitioner's agreement led to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN (as needed) ordered psychotropic drugs were limited to 14 days for a resident. Specifically, the facility did not include a 14-day stop date for a PRN Ativan order for a resident who was admitted with diagnoses including end-stage renal disease, anxiety, and a left leg above-the-knee amputation. The resident was assessed as being severely cognitively impaired and unable to participate in a mental status exam. The physician's order for Ativan, dated March 19, 2024, prescribed 0.5 milligrams every four hours as needed, but did not specify a stop date. The medication was administered on March 22, 2024, without the required stop date. During an interview, the Director of Nursing stated that she would expect a PRN order for Ativan to have a 14-day stop date and then be re-evaluated.
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 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.
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.
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.
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.
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 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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