Mill Town Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Amesbury, Massachusetts.
- Location
- 22 Maple Street, Amesbury, Massachusetts 01913
- CMS Provider Number
- 225318
- Inspections on file
- 28
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mill Town Health And Rehabilitation during CMS and state inspections, most recent first.
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.
A resident with diabetes and dementia was found on the floor, slow to respond, with facial droop and right arm weakness while lying against a hot baseboard heater. Despite facility hypoglycemia protocols and active MD orders requiring immediate blood glucose checks and treatment for low BG, nursing staff did not obtain a fingerstick BG or initiate hypoglycemia interventions before EMS arrival; EMS later found a BG of 24 mg/dL and treated the resident. Staff also recognized that the heater was very hot and observed a reddened area on the resident’s upper arm but did not provide burn first aid or fully assess for additional burn injuries, and the resident was later found at the hospital to have extensive second- and third-degree burns to the back and upper right arm.
A resident with dementia, diabetes, and vascular conditions experienced an unwitnessed fall and was found on the bathroom floor. Facility policies required initiation of a neurological assessment with specific vital and neuro checks at defined intervals for 72 hours, and complete documentation of all observations and changes in condition. Although initial neuro signs were noted as within normal limits, nursing staff documented several neurological assessments on the flow sheet without recording the times, instead entering BP values in the time field, and only one subsequent timed neuro check was recorded. No additional post-fall neurological assessments were found in the medical record, and the DON acknowledged that neuro signs were not documented as required by policy.
A resident with SUD, opioid abuse, PTSD, and depression did not receive required behavioral health services, including psychiatric talk therapy and follow-up after an incident of cocaine use that led to hospitalization. Despite facility policy and the resident's consent for therapy, only medication management was provided, and the care plan was not updated after the substance use event. Staff interviews confirmed the lack of follow-up and support.
Several residents had inaccurate MDS assessments, including incorrect documentation of pressure ulcers, restraint use, and pneumococcal vaccination status. In some cases, residents were recorded as having received or been offered vaccines when they had not, and one resident was assessed for cognition after discharge, despite not returning to the facility. Staff interviews and record reviews confirmed these discrepancies.
The facility failed to complete weekly skin checks for several residents at risk for pressure ulcers, did not ensure an air mattress was functioning for a resident requiring pressure relief, and did not perform a baseline AIMS assessment when starting an antipsychotic medication, despite physician orders and facility policy. Staff interviews confirmed these omissions and cited EMR issues, but acknowledged that assessments and monitoring should have been completed as required.
A resident with complex wounds did not receive wound care treatments as recommended by the wound physician, including the use of vashe, gauze island dressings, and bacitracin. Despite clear documentation and verbal communication of these recommendations, facility staff did not update physician orders or provide the prescribed treatments in a timely manner, resulting in a prolonged lack of appropriate wound care.
Surveyors observed that staff did not date opened medications as required, left treatment carts unlocked and unattended on multiple units, and failed to keep medication carts clean and organized. Nursing staff also left surveyors alone with unlocked medication carts and in the medication room, contrary to facility policy. These deficiencies were confirmed by interviews with nursing staff, a unit manager, and the DON.
Three residents with severe cognitive impairment, each with signed consents for pneumococcal vaccination, did not receive the vaccine as required by CDC guidelines. The Infection Preventionist was aware of the issue, citing inability to obtain the vaccine from the pharmacy, while the DON was unaware of the procurement problem. Facility policy requires administration of recommended vaccines upon consent, but this was not completed for these residents.
A resident who had multiple teeth extracted did not receive timely follow-up dental services or denture impressions, despite a documented recommendation from the dentist. The resident, who was cognitively intact and had chronic health conditions, reported waiting for months without communication from staff about the denture process. Facility staff interviews confirmed that the necessary dental follow-up was missed and the resident was not scheduled for further dental care as recommended.
A resident with an open wound, colostomy, and IR drain was not placed on Enhanced Barrier Precautions (EBP) as required. Staff assessed the resident's wounds and managed the drain using gloves but not gowns, and there was no EBP signage or care plan intervention in place. The Infection Preventionist confirmed that EBP should have been implemented for this resident.
A resident with a history of substance abuse and mental health conditions, but with intact cognition, was allowed to smoke at the facility without a completed smoking assessment or care plan as required by policy. Although the resident signed the smoking policy and participated in related groups, the facility did not document an assessment of the resident's ability to smoke safely or develop a care plan prior to permitting smoking, as confirmed by record review, observation, and DON interview.
Two residents with feeding tubes did not receive care in accordance with professional standards. One resident's enteral feeding formula and water flush bags were not changed every 24 hours, and an open formula bottle was left undated and unrefrigerated. Another resident received water flushes at a volume lower than prescribed by the physician. Staff interviews confirmed that these practices did not align with facility policy or physician orders.
A resident with a PICC line for IV medication had a dressing that was peeling and covered with gauze, obscuring the insertion site. Despite facility policy and physician orders requiring immediate dressing changes when compromised, the dressing remained in this state for several days. Nursing staff did not ensure the site was visible or the dressing was promptly changed, as confirmed by observations and documentation.
A resident with acute pain from trauma and osteoporosis was denied as-needed pain medication by a nurse, who did not assess pain using a scale or document the event. The resident, who was cognitively intact and had orders for pain evaluation and PRN analgesics, received no intervention until the next shift, when pain was documented as severe. The care plan also lacked a pain management component.
Two residents requiring continual supervision and assistance with eating were left unsupervised during meals, resulting in food spillage, distress, and lack of necessary cues or help. Despite care plans and physician orders specifying the need for supervision due to severe dementia, malnutrition, dysphagia, and dependence on staff for ADLs, staff did not remain present or provide the required support, as confirmed by observations and staff interviews.
A resident with SUD and a history of recent substance use did not receive required social services, including talk therapy and support interventions, before or after a hospitalization for illicit drug use. The care plan interventions were not implemented, and there was no timely reassessment or notification of the SUD counselor following the incident. Staff interviews confirmed gaps in the new SUD program and unclear responsibilities for providing addiction support.
A resident with a history of pain and cognitive intactness requested pain medication during the night shift but was denied by the nurse, who did not assess or document the pain or offer alternatives. The resident remained in pain until the next shift, when pain was assessed as severe and medication was provided. The incident was documented as a grievance but was not reported or investigated as suspected neglect, contrary to facility policy and regulatory requirements.
A resident who was cognitively intact and required supervision requested pain medication from a nurse, who refused to provide it and did not offer alternatives or document the pain assessment. The resident received pain relief only after the next shift began, with pain rated as severe. The facility did not conduct a timely or thorough investigation into this potential neglect, failing to follow its own policies for handling such allegations.
Three residents, including individuals with severe cognitive impairment and one who was cognitively intact, did not have their MDS assessments completed and transmitted within the required timeframes. The MDS Nurse and DON confirmed that the assessments were not submitted according to RAI manual guidelines.
The facility failed to implement comprehensive care plans for two residents. One resident's plan lacked documentation for necessary transfer assistance with a Hoyer lift, while another resident's plan did not address their preference to be barefoot. Staff were not updated on the transfer status, and the care plans did not reflect the residents' needs and preferences.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including chronic pain and lymphoma, who had a physician's order for nursing documentation of transfers in and out of bed. The nursing staff did not consistently document the resident's transfers, time in the wheelchair, or refusals, as required by the physician's order. The DON confirmed the lack of documentation.
The facility failed to ensure that nurses completed annual training and competencies for insulin-dependent residents, leading to improper management of blood glucose levels. Several residents with diabetes experienced instances where nurses did not follow physician orders or notify physicians when necessary. The Director of Nursing could not provide documentation of annual competencies for the involved nurses.
The facility failed to notify physicians or nurse practitioners of significant changes in the status of residents with diabetes, leading to a deficiency in care. Multiple residents experienced low blood glucose levels, and the nursing staff did not follow the facility's policy to notify healthcare providers. Interviews confirmed that the staff did not adhere to the hypoglycemic protocol, resulting in a deficiency in the standard of care.
The facility failed to administer insulin according to physician orders and facility policy for several residents with diabetes. Nursing staff administered insulin despite low blood glucose levels and did not follow the hypoglycemic protocol, failing to notify physicians or document interventions. Interviews revealed a lack of adherence to protocols and communication issues regarding held medications.
The facility failed to comply with food service safety standards, as observed by surveyors. Deficiencies included a dented can of peppers in dry storage and various undated or spoiled food items in the walk-in refrigerator, such as deli meats and egg salad. Opened but undated bottles of juices and milk were also found in unit refrigerators. Interviews confirmed that all opened food and drinks should be labeled and dated, and dented cans should be set aside for return. The facility's failure to adhere to these standards resulted in the identified deficiencies.
A resident with a history of stroke and hemiparesis did not receive necessary rehabilitation services after refusing to wear a prescribed hand splint. The facility's failure to follow up on the resident's condition and the Nurse Practitioner's concerns about a hand contracture led to a deficiency. Communication breakdowns between nursing, rehabilitation services, and an orthotic provider contributed to the oversight.
A resident with end-stage renal disease had a fistula in the right arm, and the care plan specified not to take blood pressure from this arm. Despite this, nursing staff documented using the right arm for blood pressure readings multiple times, although interviews revealed the left arm was used. The DON expected accurate documentation, highlighting a failure in maintaining accurate medical records.
A facility failed to ensure timely acknowledgment and action on a consultant pharmacist's recommendations for a resident's medication regimen. The resident, with severe cognitive impairment, was prescribed Risperdal for dementia with behavioral disturbances. Despite multiple recommendations to clarify the diagnosis, the necessary updates were delayed due to interim physician coverage and lack of communication, leading to a deficiency.
A resident at risk for pressure ulcers had their air mattress set incorrectly at 400 lbs instead of the physician-ordered 100 lbs. Despite the care plan's inclusion of pressure-relieving devices, the error persisted for three days, as confirmed by surveyor observations and acknowledged by the unit manager.
A resident with moderate cognitive impairment and a history of falls experienced multiple unwitnessed falls due to the facility's failure to promptly integrate fall prevention interventions into the care plan. Despite policy requirements for immediate action, the intervention to educate the resident on call light usage was delayed, leading to further falls.
The facility failed to create trauma-informed care plans with individualized interventions for three residents with a history of trauma. A resident reported an allegation of rape, but the facility did not complete a PTSD assessment or develop a specific care plan. Two other residents with PTSD also lacked comprehensive care plans with identified triggers and interventions. The social worker acknowledged the need for formal assessments and personalized care plans.
A resident with moderately impaired cognition reported being raped by a family member, but the facility failed to implement a plan to protect the resident and others. Despite the ongoing investigation, the alleged perpetrator was allowed to visit the facility without restrictions, contrary to the facility's abuse prevention policy. Staff interviews revealed a lack of communication and action to restrict the alleged perpetrator's access until the issue was raised by a surveyor.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident did not receive necessary adaptive feeding equipment during meals, while another's bed was not maintained in the low position as required. Additionally, weekly skin assessments were not performed for a resident at high risk for skin breakdown due to a system error.
The facility failed to provide adequate supervision and assistance with ADLs for three residents. One resident with dysphagia and dementia was left unsupervised during meals, contrary to their care plan. Another resident with severe cognitive impairment was also left alone during meals, leading to improper eating habits. A third resident, requiring assistance for bathing, reported not receiving scheduled showers, with no documentation of care refusals. Staff interviews revealed inconsistencies in following care plans and physician orders.
The facility failed to obtain consents for psychotropic medications for two residents before administration. One resident with manic depression was given Paxil without consent, and another with severe cognitive impairment was prescribed Ativan without informed consent. Staff interviews confirmed the absence of required consents.
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.
Failure to Assess and Treat Hypoglycemia and Burns After Unwitnessed Fall
Penalty
Summary
Nursing staff failed to follow professional standards and physician orders for hypoglycemia management for a resident with diabetes who was found on the floor after an unwitnessed fall. The facility’s hypoglycemia policy and protocol required staff to recognize signs and symptoms of hypoglycemia, obtain a fingerstick blood glucose, and administer carbohydrates or IM glucagon for blood glucose levels under 70 mg/dL, followed by physician notification. The resident had active physician orders to administer 15–20 g of carbohydrates and reassess every 15 minutes if blood glucose was less than or equal to 70 mg/dL, to check blood glucose every 15 minutes until EMS arrival if unresponsive with blood glucose less than 70 mg/dL, and to administer 1 mg IM glucagon if unable or unwilling to swallow. Despite these orders, when the resident was found on the floor, slow to respond, with facial droop and inability to hold up the right arm, nursing staff did not obtain a fingerstick blood glucose or initiate the hypoglycemia protocol. The resident, admitted in 2017 with diagnoses including dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and a chronic right calf ulcer, was discovered at approximately 3:30 p.m. lying on the floor on the right side, leaning against a baseboard heater. The unit manager observed stroke-like symptoms, including facial droop and right arm weakness, and contacted the nurse educator, who was informed of stroke-like symptoms and stable vital signs. Neither the unit manager nor the nurse educator considered or requested a blood glucose check at that time, despite knowledge that the resident was diabetic and that hypoglycemia symptoms can mimic stroke. EMS arrived about 20 minutes later, obtained a fingerstick blood glucose of 24 mg/dL, and administered oral glucose and 1 mg IM glucose, after which the resident became more alert and responsive. Facility documentation, including the MAR, contained no evidence that nursing staff had checked the resident’s blood glucose or provided hypoglycemia treatment prior to EMS arrival. Nursing staff also failed to assess and provide first aid for potential burn injuries after the resident was found lying against the baseboard heater. Facility burn first-aid policy required assessment and first aid to relieve pain and prevent infection. The unit manager recognized that the heater was very hot, could not keep her hand between the resident and the heater for more than a few seconds, and acknowledged the resident was at risk for a burn. After moving the resident off the floor and back to bed with assistance from CNAs, the unit manager noted a reddened area on the outside of the upper right arm that she believed was a burn but did not administer first aid or assess the resident’s back for additional injuries. Subsequent hospital documentation identified a large burn with skin sloughing on the back and right arm and deep partial thickness second- and third-degree burns to the back and upper right arm from contact with the baseboard radiator.
Failure to Complete and Accurately Document Neuro Checks After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident following an unwitnessed fall. Facility policy on Charting and Documentation required that all services provided, observations, and any changes in a resident’s medical or mental condition be documented in the medical record. The Falls policy required that, after an unwitnessed fall, a Neurological Assessment be initiated and neurological signs be taken and documented for a minimum of 72 hours. The Neurological Assessment policy specified that the assessment included cognitive status, pupillary response, blood pressure, heart rate, temperature, respirations, and grip strength, with a defined frequency schedule over a 72-hour period. Resident #1, admitted in July 2017 with diagnoses including dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and a chronic ulcer of the right calf, was found sitting on the bathroom floor after an unwitnessed fall at 4:15 p.m. on 01/22/26. The facility’s Falls and Incident Assessment Tool documented that the resident’s neurological signs were within normal limits on initial assessment. However, review of the Neurological Assessment flow sheet for that date showed three neurological assessments documented without any times recorded; the space designated for time entries had been filled in with blood pressure readings instead. Only one additional neurological assessment was documented at 3:00 a.m. on 01/23/26, with no further post-fall neurological assessments found in the flow sheet or the medical record. During interview, the DON confirmed that nursing staff should have documented the resident’s neurological signs after the unwitnessed fall according to facility policy but had not done so.
Failure to Provide Required Behavioral Health Services for Resident with SUD
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a diagnosis of Substance Use Disorder (SUD), opioid abuse, PTSD, and major depressive disorder. Despite the facility's policy requiring individualized treatment and ongoing behavioral health support, the resident did not receive psychiatric talk therapy or consistent follow-up from behavioral health services. The resident had consented to both medication management and talk therapy, but records show only medication management was provided, and there was no evidence of talk therapy or regular counseling sessions. After the resident was hospitalized for acute intoxication due to cocaine use, there was no documented reassessment by the SUD counselor, social worker, MD, or NP upon the resident's return. The care plan was not updated to address the recent substance use incident, and no new interventions were added. The facility's own policies required care plan updates and education following such events, but these steps were not taken. Additionally, the resident was not offered support groups such as Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) upon admission or after the incident. Interviews with facility staff, including the social worker, DON, NP, SUD counselor, and medical director, confirmed that the required behavioral health services and follow-up were not provided. Staff cited reasons such as lack of time, newness of the SUD program, and unclear roles and responsibilities. The resident expressed a desire for more support and talk therapy, indicating unmet behavioral health needs during their stay.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for six residents, resulting in multiple inaccuracies in resident records. For one resident with diagnoses including necrotizing fasciitis, septicemia, and diabetes mellitus, the MDS assessments repeatedly documented the presence of stage four pressure ulcers, despite the medical record and staff interviews confirming that the resident never had pressure ulcers during their admission. Both the MDS nurse and the Director of Nursing (DON) acknowledged that these MDS entries were inaccurate. Another resident with Alzheimer's disease and severe cognitive impairment was incorrectly coded on the MDS as using bedrails daily as physical restraints. Observations and record reviews showed that the resident's bed did not have bedrails, and there was no documentation of restraint use in the care plan or assessment records. Staff interviews confirmed that bedrails were not used for this resident and that the MDS coding was inaccurate. Additionally, three residents were inaccurately coded regarding their pneumococcal vaccination status. In two cases, the MDS indicated that the residents were up to date with the vaccine, but medical records showed that although consent was obtained, the vaccine had not been administered due to unavailability from the pharmacy. In another case, the MDS stated the vaccine was not offered, but documentation showed that consent had been signed. For another resident, an MDS assessment was completed after a hospital transfer, indicating a staff assessment of cognition, even though the resident did not return to the facility, making such an assessment impossible. Staff interviews confirmed these inaccuracies.
Failure to Complete Required Skin Checks, Equipment Monitoring, and Baseline Assessments
Penalty
Summary
Multiple deficiencies were identified in the facility's provision of care, specifically related to the failure to ensure that services met professional standards of quality. Several residents with significant risk factors for skin breakdown, including severe cognitive impairment, immobility, and high or moderate risk scores on the Norton Scale, did not receive weekly skin checks as ordered by their physicians and as required by facility policy. In several cases, the electronic medical record (EMR) system upgrade was cited as a reason for missed or unscheduled assessments, but staff interviews confirmed that the expectation was for weekly skin checks to be completed regardless of EMR issues. Documentation for these assessments was missing for multiple weeks for several residents, and in one case, a skin check was started but left incomplete and unsigned. One resident, who was dependent for all functional tasks and at high risk for pressure ulcers, did not have weekly skin checks completed for four consecutive weeks. Another resident, also at high risk, missed several weekly skin checks over a two-month period. A third resident, with moderate risk for pressure ulcers, had no physician order for weekly skin checks and missed two scheduled assessments. Staff interviews confirmed that all residents at risk should have weekly skin checks and appropriate physician orders, and that the lack of completed assessments was not justified. Additional deficiencies included the failure to ensure that a resident's air mattress, used for pressure ulcer prevention, was functioning. The air mattress was observed to be deflated and non-functional on multiple occasions, and there was no physician order or care plan documentation for its use or settings. Staff acknowledged that the lack of an order contributed to the failure to check the mattress function regularly. Furthermore, for a resident started on an antipsychotic medication, the required baseline AIMS (Abnormal Involuntary Movement Scale) assessment was not completed upon admission or at the initiation of the medication, despite pharmacy recommendations and staff acknowledgment of the requirement.
Failure to Implement Wound Physician Recommendations for Wound Care
Penalty
Summary
The facility failed to review and implement wound physician treatment recommendations for a resident with significant medical conditions, including necrotizing fasciitis, septicemia, and diabetes mellitus. The resident was cognitively intact and had documented care plans and protocols in place for skin impairment and wound care, which required weekly monitoring and adherence to physician-ordered treatments. Despite these protocols, the facility did not update or implement the wound physician's recommendations for wound care treatments over several months, as evidenced by a lack of corresponding physician orders and treatment administration records. The wound physician made specific recommendations for the treatment of the resident's post-surgical right buttock wound and an abdominal skin tear, including the use of hypochlorous acid solution (vashe), gauze island dressings, and bacitracin. These recommendations were documented in the wound evaluation and management summaries and communicated verbally to facility staff. However, the facility's physician orders did not reflect these recommendations, and the recommended treatments were not initiated in a timely manner. For example, the order to apply gauze to the abdominal wound was not implemented until 50 days after the initial recommendation and only after the surveyor raised the concern. Interviews with nursing staff, the unit manager, nurse practitioner, medical director, and wound physician revealed a lack of awareness and follow-through regarding the implementation of the wound physician's recommendations. Staff members assumed that the recommended treatments were in place, but documentation and direct observation confirmed that the orders had not been updated and the treatments were not being provided as prescribed. The facility's failure to ensure that wound care recommendations were reviewed and implemented resulted in a deficiency in providing appropriate treatment and care according to physician orders and the resident's needs.
Failure to Properly Store, Label, and Secure Medications and Treatment Carts
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, as evidenced by multiple observations of opened medications, such as inhalers and liquid supplements, that were not dated upon opening. Manufacturer guidelines for these medications require discarding after a specified period post-opening, but staff did not label them with the date they were first used. Interviews with nursing staff, a unit manager, and the DON confirmed that medications with shortened expiration dates should be dated when opened, but this was not consistently done. Treatment carts containing medicated ointments and creams were repeatedly found unlocked and unsupervised on both the second and third floor units. Surveyors were able to access these carts, and multiple staff members and residents were observed passing by the unsecured carts. Staff interviews confirmed that treatment and medication carts are expected to be locked at all times unless attended by a nurse, but this protocol was not followed during the survey. Medication carts were also found to be disorganized and unclean, with observations including a bottle of liquid medication without a cover, loose pills, and a sticky red substance spilled inside the cart. Additionally, nursing staff left surveyors unattended with unlocked medication carts and in the medication room, contrary to facility expectations that staff should remain present during such inspections. These lapses were acknowledged by the staff, unit manager, and DON during interviews.
Failure to Administer Pneumococcal Vaccines per CDC Recommendations
Penalty
Summary
The facility failed to administer pneumococcal vaccinations according to CDC recommendations for three residents who had provided signed consents for the vaccine. All three residents had severe cognitive impairment and had consents for the pneumococcal vaccine documented in their medical records. However, there was no evidence in the medical records that the vaccine was actually administered to any of these residents, despite the consents being in place. Interviews with the Infection Preventionist revealed that she was aware of the lack of vaccine administration and attributed it to the facility's inability to obtain the vaccine from the pharmacy. The Director of Nurses was not aware of the issue with vaccine procurement and stated that the vaccine should have been administered if consent was obtained. The facility's policy requires that all residents receive recommended immunizations unless contraindicated, refused, or otherwise ordered by a physician, and that consent and orders for vaccines be obtained at admission, but these procedures were not followed through to completion for the affected residents.
Failure to Provide Follow-Up Dental Services and Dentures
Penalty
Summary
The facility failed to provide follow-up dental services and obtain dentures for one resident who had previously undergone multiple tooth extractions. The resident, who was cognitively intact and had a history of Alzheimer's Disease, diabetes, heart failure, and muscle weakness, reported that after having teeth extracted months prior, they had been waiting to be measured for dentures and had not been informed by staff about the process. Review of the medical record showed a signed consent for dental treatment, a physician's order for dental consults as needed, and documentation of the extractions and a follow-up dental visit. The dental note from the follow-up visit recommended another four weeks of healing before starting denture impressions, with a next visit planned for the first step in denture fitting if approved. However, there was no evidence in the medical record that the denture impressions were completed or that the facility contacted the dental service to ensure this occurred. Interviews with facility staff revealed that the resident had not been seen by the dentist since the extractions, and the process for obtaining dentures was missed. The Director of Nursing and Unit Manager both indicated that the responsibility for scheduling dental appointments and following up on recommendations was shared between the Medical Record Director and nursing staff, but the recommendation for dentures was not acted upon, resulting in the resident not receiving necessary dental follow-up.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Medical Devices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not applying Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors, including an open wound, colostomy, and an interventional radiology (IR) drain. Observations revealed that the resident did not have an EBP sign on or near the door, and staff, including a unit manager, assessed the resident's wounds and manipulated the IR drain while wearing gloves but not gowns, as required by EBP protocols. The care plan for the resident did not include interventions for EBP, and there was no physician's order for EBP in the resident's medical record. The resident had a history of necrotizing fasciitis, septicemia, and diabetes mellitus, and was cognitively intact at the time of the deficiency. Physician's orders included wound care, colostomy care, and management of the IR drain, but did not address EBP. The Infection Preventionist confirmed that the resident should have been on EBP, with appropriate signage, care plan interventions, and staff use of gowns during high-contact care activities, but acknowledged these measures were not in place.
Failure to Complete Smoking Assessment and Care Plan for Resident
Penalty
Summary
The facility failed to implement safe smoking practices for one resident who smoked cigarettes. Specifically, the facility did not complete a smoking assessment or develop a care plan for the resident prior to allowing them to smoke on the premises. Although the resident had signed the facility's smoking policy and participated in smoking groups and cessation counseling, there was no documentation of a formal assessment of the resident's cognitive and physical abilities to smoke safely, as required by facility policy. The policy mandates that such assessments be conducted upon admission, with changes in status, and at least quarterly, with the interdisciplinary team reviewing the results to determine a safe smoking plan. The resident in question was admitted with a history of opioid abuse, psychoactive substance abuse, post-traumatic stress disorder, and major depressive disorder, but was assessed as having intact cognition. Despite this, the lack of a documented smoking assessment and care plan meant that the facility did not ensure adequate supervision or safety measures were in place before the resident engaged in smoking. The deficiency was confirmed through record review, observation of the resident smoking outside with staff present, and interview with the DON, who acknowledged the expectation for a smoking assessment and care plan to be completed upon admission for residents who smoke.
Failure to Follow Enteral Feeding Protocols and Physician Orders
Penalty
Summary
Two residents with feeding tubes experienced deficiencies in the provision of care according to professional standards. One resident, admitted with a history of stroke, diabetes, and malnutrition, was assessed as severely cognitively impaired and dependent on enteral feeding. Observations revealed that the resident's enteral feeding formula and water flush bags were not changed every 24 hours as required, with both bags labeled three days prior to the observation. Additionally, an open bottle of formula was found on the bedside table, undated and unrefrigerated, contrary to facility policy and staff statements that all open formula bottles should be dated and refrigerated after opening. Another resident, admitted with gastroparesis, severe malnutrition, and psychosis, was cognitively intact and also required a feeding tube. This resident's physician orders specified water flushes of 60 ml every four hours via both G and J tube ports. However, multiple observations showed that the water flushes were set at 50 ml every four hours, not in accordance with the prescribed orders. Staff interviews confirmed that the water flush setting was incorrect and should have matched the physician's order. Facility policy required that enteral feeding formula and water flush bags be changed every 24 hours and that open formula bottles be dated and refrigerated. The failure to follow these procedures for both residents was confirmed by nursing staff, the unit manager, the dietitian, and the DON, all of whom acknowledged the discrepancies between practice and policy or physician orders.
Failure to Maintain and Change Compromised PICC Line Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) line consistent with professional standards of practice for one resident. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra, intraspinal abscess, and low back pain, was receiving IV medications through a PICC line. Observations revealed that the PICC line dressing was peeling off and the insertion site was covered with gauze, preventing visualization of the site. The resident reported having to apply tape to the dressing for several days due to it peeling off. Despite facility policy and physician orders requiring immediate dressing changes if the dressing was compromised, the dressing remained in a compromised state for an extended period. Nursing documentation and direct observation confirmed that the PICC line dressing was lifting and the insertion site was not visible, which is inconsistent with both facility policy and professional standards that require the site to be visible and the dressing to be changed immediately if compromised. The DON stated that nurses are expected to observe the PICC line during each room entry and to change the dressing immediately if it begins to lift. However, these expectations were not met, as evidenced by the ongoing compromised dressing and lack of site visibility.
Failure to Assess and Provide Pain Management for Resident with Acute Pain
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of acute pain due to trauma, osteoporosis with pathological vertebral fracture, and muscle weakness was not properly assessed or treated for pain. The resident, who was cognitively intact and required supervision for functional tasks, requested Tylenol for pain in the shoulders, hips, and back during the overnight shift. The nurse on duty denied the request, stating she did not believe the resident was in pain, and did not offer any alternative interventions. Documentation shows that the resident was not given any pain medication during that shift, and there was no use of a pain scale or nursing note to document the assessment. The resident later received Tylenol from the next shift nurse, at which time the pain was assessed as 8 out of 10. Review of the resident's physician orders at the time included scheduled and as-needed pain medications, as well as instructions for pain evaluation every shift. However, the Medication Administration Report did not reflect administration of pain medication or proper pain assessment during the shift in question. Additionally, the resident's care plan did not include a plan for pain management at the time of the survey. Interviews with facility staff confirmed that the nurse did not adequately manage the resident's pain according to facility policy and physician orders.
Failure to Provide Required Supervision and Assistance with Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically supervision and cueing during meals, for two residents. One resident with severe dementia and chronic malnutrition was repeatedly observed alone in their room during breakfast, attempting to self-feed but dropping food and spilling liquids on themselves. Despite care plans and Kardex instructions requiring continual supervision and verbal cues during meals, staff were not present to assist or encourage the resident, resulting in significant food spillage and distress. Interviews with staff confirmed that the resident required total assistance and should not have been left alone during meals. Another resident with anoxic brain damage, aphasia, dysphagia, and a history of cerebral infarction was also observed eating alone in bed without staff supervision. This resident, who is cognitively intact but dependent on staff for ADLs and requires continual supervision and assistance with eating, was found with food and liquids spilled on their body and reported being in an uncomfortable position to eat. The resident was also observed coughing on fluids, and staff interviews confirmed that the resident was not receiving the required supervision during meals as outlined in their care plan and physician's orders. Both residents had care plans and Kardex instructions specifying the need for continual supervision and assistance with eating, including monitoring for signs of dysphagia and providing help with hot liquids. However, staff failed to follow these directives, leaving the residents unsupervised during meals and not providing the necessary cues or assistance, as confirmed by direct observation and staff interviews.
Failure to Provide Medically Related Social Services for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide medically related social services to a resident with an active diagnosis of Substance Use Disorder (SUD). The resident was admitted with a history of opioid and psychoactive substance abuse, PTSD, and major depressive disorder, and had recently used substances prior to admission. Despite facility policies requiring individualized treatment, assessment by a substance use clinician, and ongoing behavioral health support, the resident did not receive talk therapy services or documented substance use support prior to or after a hospitalization related to illicit drug use. The resident's care plan included interventions such as assistance with treatment programs, therapeutic discussions, and development of coping strategies, but there was no evidence that the social worker implemented these interventions. After the resident was hospitalized and tested positive for cocaine, there was no reassessment or updated care plan by the social worker, nor was the SUD counselor notified in a timely manner. The resident expressed a desire for more support and indicated that additional services were only offered after the incident. Interviews with facility staff, including the social worker, DON, SUD counselor, NP, and medical director, revealed that the SUD program was new and that roles and responsibilities were unclear. The social worker acknowledged not providing addiction support or setting up virtual addiction meetings, and the SUD counselor was unaware of the resident's drug use until several days after the event. The DON and medical director confirmed that the expected reassessment and support services were not provided following the resident's substance use incident.
Failure to Report and Investigate Suspected Neglect Related to Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to report a potential allegation of neglect involving a resident who was cognitively intact and required supervision for functional tasks. The resident, who had a history of acute pain due to trauma, osteoporosis with pathological fracture, and muscle weakness, requested Tylenol for pain during the night shift. The nurse on duty denied the request, stating she did not believe the resident was in pain, and did not offer any alternative interventions. The resident waited until the next shift to request pain relief and was found to be in significant pain, assessed as 8 out of 10, and was in tears. Facility policy required that any suspicion or observation of abuse, neglect, or misappropriation of resident property be immediately reported to the appropriate authorities and thoroughly investigated. The policy also specified that such incidents should be reported to the unit manager or supervisor, and subsequently to the Administrator or DON. In this case, the incident was documented as a grievance by a staff member, but there was no evidence that it was reported as a potential neglect incident or that a full investigation was conducted as required by policy. The Director of Nursing, upon review of the grievance and medication administration records, acknowledged that the nurse did not adequately manage the resident's pain and that the incident should have been investigated and reported as neglect. The incident was not reported to the state agency, and a full investigation was not completed, which constituted a failure to follow facility policy and regulatory requirements for reporting suspected neglect.
Failure to Investigate Alleged Neglect in Pain Management
Penalty
Summary
The facility failed to fully investigate a potential allegation of neglect involving a resident who was cognitively intact and required supervision for functional tasks. According to the grievance, the resident requested Tylenol for pain from the night nurse, who refused to provide it, stating she did not believe the resident was in pain. The nurse did not offer any alternative interventions, and the resident waited until the next shift to request pain relief, at which point the pain was assessed as severe (8 out of 10) and medication was administered. The medical record and MAR confirmed that no pain medication was given by the night nurse, and there was no documented pain assessment or nursing note for that shift. The facility's policies require immediate and thorough investigation of any allegations or suspicions of neglect, including timely interviews with all involved parties and documentation of findings. In this case, the grievance was written by a staff member, but there was no indication that the staff member who reported the concern was interviewed. The nurse implicated in the grievance provided a written statement two weeks after the incident, which was not timely. The Director of Nursing acknowledged that the nurse did not adequately manage the resident's pain and that the incident should have been investigated as potential neglect, rather than being handled solely as a grievance. Additionally, the resident was sent to the hospital a week after the incident, though the report does not link this directly to the pain management issue. The Director of Nursing could not recall seeing that the medication was not given at the time and confirmed that the investigation was incomplete. The facility did not follow its own policies for investigating allegations of neglect, resulting in a failure to respond appropriately to the alleged violation.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required timeframe for three residents. According to the CMS Resident Assessment Instrument (RAI) Manual, assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted within 7 days of completion. For three residents, the MDS assessments were not completed or submitted within these required timeframes. Specifically, one resident with severe cognitive impairment had an MDS assessment completed 24 days after the ARD and submitted 26 days after the ARD. Another resident, who was cognitively intact, had an MDS assessment completed 26 days after the ARD and submitted 28 days after the ARD. A third resident with severe cognitive impairment had an MDS assessment completed 20 days after the ARD. Interviews with the MDS Nurse and the Director of Nurses confirmed that the assessments were not completed and submitted according to the RAI manual requirements. The MDS Nurse acknowledged that quarterly MDS assessments should be submitted within 14 days of the ARD, but this was not done for the three residents in question. The Director of Nurses also stated that he would expect MDS assessments to be completed and submitted as per the RAI manual, which did not occur in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not include the necessary transfer status, which required assistance from two staff members using a Hoyer lift. Despite trials with a sit-to-stand lift, it was determined that the resident lacked the upper body strength for its safe use, necessitating the Hoyer lift. However, this information was not documented in the resident's care plan, and nursing staff were not updated about the failed trials. The resident's care plan also lacked documentation for daily transfers out of bed, despite being dependent on staff for transfers. Another resident's care plan failed to address their preference to be barefoot, despite observations and staff interviews confirming this preference. The resident, who had diagnoses including dementia and schizophrenia, was observed barefoot in the dining room, and staff noted that the resident would remove socks and shoes if they were put on. The care plan only included encouragement to wear appropriate footwear, without addressing the resident's preference to remain barefoot. The Director of Nursing acknowledged that the care plan should have included this preference but did not.
Incomplete Nursing Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a physician's order requiring nursing documentation every shift regarding transfers in and out of bed. The resident, admitted in March 2024, had multiple diagnoses including chronic pain, lymphoma, metabolic encephalopathy, lymphedema, and generalized anxiety disorder. The physician's order specified that nursing notes should document the times the resident was assisted to and from their wheelchair, any refusals, and the number of attempts made. However, the nursing progress notes for January 2025 through February 10, 2025, were found to be insufficient, inconsistent, or entirely missing on several dates. The facility's policy on charting and documentation required all observations and services performed to be recorded in the resident's medical record. Despite this, there were numerous instances where the nursing staff failed to document the resident's transfers, the time spent in the wheelchair, or the resident's tolerance of the activity. On several occasions, there was no documentation of staff attempts to assist the resident or the resident's refusals to transfer. The Director of Nurses acknowledged that the nurses had not documented the resident's transfers as per the physician's orders.
Failure to Ensure Nursing Competencies for Insulin Management
Penalty
Summary
The facility failed to ensure that three out of thirteen nurses completed annual training and competencies related to the provision of care and services for insulin-dependent residents. This deficiency was identified through a review of records, policies, staff education records, and interviews. Specifically, the facility did not notify the physician or nurse practitioner when residents' blood glucose levels fell below parameters or when insulin was held due to hypoglycemia. Additionally, the facility did not follow physician orders for when to give or hold insulin based on blood glucose levels. Several residents were affected by this deficiency. Resident #9, who was admitted with diagnoses including type II diabetes mellitus, hypertension, and dementia, had instances where nurses failed to follow physician orders and incorrectly administered insulin when blood glucose levels were less than 150 mg/dl. Resident #79, with diagnoses including type II diabetes mellitus and renal failure, had a severely low blood glucose level recorded without any indication that the hypoglycemic protocol was initiated or that the physician was notified. Similar issues were noted with Resident #48, who had a blood glucose level of 19 recorded without appropriate action being taken. The Director of Nursing was unable to provide documentation of annual competencies for the involved nurses, indicating a lapse in ensuring that staff were adequately trained to manage insulin-dependent residents. This lack of documentation and training contributed to the failure in providing appropriate care and following established protocols for managing diabetes in residents.
Failure to Notify Physicians of Low Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of significant changes in the status of five residents with diabetes, leading to a deficiency in care. The facility's policy required that nursing staff document findings and notify the physician when blood glucose levels fell below specified parameters. However, the review of medical records revealed multiple instances where residents' blood glucose levels were below the ordered parameters, and the nursing staff did not notify the physician or nurse practitioner as required. Resident #9, who had severe cognitive impairment and was dependent on staff for daily activities, experienced several instances of low blood glucose levels. Despite the facility's policy and physician's orders to notify the provider if blood glucose was below 70, the nursing staff failed to do so on multiple occasions. Interviews with various nurses and the Director of Nursing confirmed that the staff did not follow the hypoglycemic protocol, and the critically low blood glucose level of 31 on one occasion was not reported. Similarly, other residents, including Resident #79, Resident #48, Resident #58, and Resident #60, experienced low blood glucose levels without appropriate notification to their healthcare providers. In some cases, insulin was held due to low blood sugar, but the lack of communication with the physician or nurse practitioner was consistent across these cases. Interviews with the medical director and nurse practitioners highlighted the expectation for staff to notify them of such incidents, which was not met, leading to a deficiency in the standard of care provided.
Failure to Administer Insulin According to Orders and Protocol
Penalty
Summary
The facility failed to administer insulin to residents diagnosed with diabetes according to physician orders and facility policy. For Resident #9, the nursing staff repeatedly administered insulin glargine despite blood glucose levels being below the physician-ordered parameter of 150 mg/dl. On several occasions, the staff did not follow the hypoglycemic protocol when blood glucose levels were critically low, failing to administer carbohydrates, recheck blood glucose levels, or notify the physician. Interviews with nursing staff revealed a lack of adherence to the protocol and physician orders, with some staff unable to recall specific hypoglycemic episodes or the facility's protocol. Resident #79 experienced a severe hypoglycemic event with a blood glucose level recorded at 15 mg/dl, yet there was no documentation of the hypoglycemic protocol being initiated or the physician being notified. Similarly, Resident #48 had a blood glucose level of 19 mg/dl, but the nursing staff did not follow the protocol or notify the physician. In both cases, the nurses involved suggested that the low readings might have been typographical errors, indicating a potential issue with documentation accuracy. Resident #58 had low blood glucose levels on two occasions, but the hypoglycemic protocol was not followed, and the physician was not notified. Resident #60 had multiple instances where insulin was held due to low blood glucose levels, but there was no documentation of physician notification. Interviews with staff, including the Nurse Practitioner, highlighted a lack of communication regarding held medications, which could lead to inappropriate dosing. The Director of Nursing acknowledged that medications should be held per parameters or nursing judgment, but emphasized the importance of notifying the physician and documenting the decision.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The surveyor noted several deficiencies in the storage and labeling of food items. A significantly dented can of ready-to-eat peppers was found on the can-rack in the dry-storage area, which should have been removed according to the facility's policy. Additionally, various food items in the walk-in refrigerator were either undated or past their discard date, including a package of salami, deli meats, egg salad, milk, and orange juice. These items were not labeled or dated as required, and some exhibited signs of spoilage, such as a pungent odor and pale appearance. Further observations in the refrigerators on the third and second floors revealed opened but undated bottles of juices and milk. Interviews with the Food Service Director (FSD) and a nurse confirmed that all opened food and drinks should be labeled and dated, and that dented cans should be set aside for return to the vendor. The FSD acknowledged that the dented can of cranberry sauce found during a follow-up observation was missed during the weekly check. The facility's failure to properly label, date, and store food items, as well as to segregate dented cans, led to the identified deficiencies.
Failure to Provide Rehabilitation Services for Contracted Hand
Penalty
Summary
The facility failed to provide necessary rehabilitation services for a resident who had a history of stroke and hemiparesis, leading to a contracted hand. The resident was admitted with conditions including right hemiparesis and was noted to have a tightly closed right hand without a splint during a surveyor's observation. The facility's policy required rehabilitation screening and referrals for changes in residents' status, but this was not adequately followed for the resident in question. The resident had previously been discharged from occupational therapy with a hand splint and instructions for its use. However, the resident refused to wear the splint, and the order for its use was discontinued without a follow-up evaluation. The Nurse Practitioner expressed concern about the resident's hand contracture and consulted an orthotic service, but the resident was not evaluated as planned. The lack of communication and follow-up between the nursing staff, rehabilitation services, and the orthotic provider contributed to the deficiency. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The Director of Rehab Services and the Occupational Therapist were not informed of the resident's refusal to wear the splint or the NP's concerns. The facility's rehabilitation screening process did not prompt an evaluation despite the resident's refusal of the splint, and there was no active order for rehabilitation services to address the resident's needs. This oversight resulted in the resident not receiving the necessary evaluation and intervention to prevent further contracture and maintain skin integrity.
Inaccurate Documentation of Blood Pressure Readings
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident diagnosed with end-stage renal disease, who was admitted in January 2024. The resident had a fistula in the right arm, and the care plan explicitly stated that blood pressure readings should not be taken from this arm. Despite this, nursing staff documented that they obtained blood pressure readings from the resident's right arm on multiple occasions between March and June 2024. This documentation was inconsistent with the resident's care plan and the sign above the resident's bed, which instructed staff not to use the right arm for such procedures. Interviews with the resident and nursing staff revealed that blood pressure readings were actually taken from the resident's left arm, contradicting the documentation. The resident confirmed that staff never used the right arm for blood pressure readings. Several nurses, including the Nurse Unit Manager, admitted to documenting the use of the right arm in error. The Director of Nursing expressed that the expectation was for nurses to accurately document the procedures performed, indicating a lapse in maintaining accurate medical records for the resident.
Failure to Address Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for one resident. The facility's policy requires the consultant pharmacist to review each resident's medication regimen monthly and report findings to the Director of Nursing (DON) and the Medical Director. However, for Resident #81, who has severe cognitive impairment and is prescribed Risperdal for dementia with behavioral disturbances, the pharmacist's recommendations to clarify the diagnosis were not addressed promptly. The recommendations were made on multiple occasions, but the necessary diagnosis was not entered into the medical record until much later. Interviews with facility staff revealed that there was a breakdown in the process of managing the MMRs. The Nurse Unit Manager stated that during a period when interim physicians were covering the facility, the pharmacy recommendations were not signed off. The DON was unaware of this issue and expected recommendations to be addressed within 7-10 days. This lack of timely action and communication led to the deficiency in addressing the pharmacist's recommendations for Resident #81's medication regimen.
Incorrect Air Mattress Pressure Setting for Resident
Penalty
Summary
The facility failed to set the air mattress pressure to the correct, physician-ordered setting for a resident who was at risk for pressure ulcers. The resident, who had diagnoses including diabetes and cerebral vascular accident, was receiving hospice services and had moderately impaired cognitive skills. The physician's order specified that the air mattress should be set to 100 pounds, but for three consecutive days, the mattress was observed to be set at 400 pounds. The resident's care plan included the use of pressure-relieving devices due to the risk of developing pressure ulcers. Despite this, the air mattress pressure was not adjusted according to the physician's order. Observations by the surveyor on multiple occasions confirmed the incorrect setting, and the unit manager acknowledged the discrepancy, noting that the pressure should have been set to 100 pounds based on the resident's weight.
Failure to Implement Timely Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as Resident #74, who was at moderate risk for falls due to dementia, confusion, deconditioning, gait/balance problems, psychoactive drug use, and unawareness of safety needs. The resident experienced an unwitnessed fall in their room, and the facility's policy required immediate assessment and implementation of a fall prevention plan. However, the intervention discussed at the risk meeting to prevent future falls was not integrated into the resident's care plan until two days after the fall. The facility's policy on falls, revised in June 2022, mandates that after a fall, an Incident and Accident Investigation and an Incident/Accident Report must be completed by a licensed nurse. The nurse is also responsible for implementing a fall prevention plan immediately and updating the resident's care plan. Despite these requirements, the intervention to educate the resident on call light usage was delayed, and the resident experienced another unwitnessed fall in the bathroom shortly after the first incident. Interviews with facility staff, including a CNA, a nurse, the Nurse Unit Manager, and the DON, revealed that the post-falls procedure was not followed as expected. The staff acknowledged that the intervention should have been integrated into the care plan immediately during the risk meeting. The failure to promptly update the care plan and implement the discussed intervention put the resident at risk for future falls, as noted by the Nurse Unit Manager and the DON.
Failure to Develop Trauma-Informed Care Plans for Residents
Penalty
Summary
The facility failed to develop trauma-informed care plans with individualized interventions for three residents with a history of trauma. Resident #70, who has a diagnosis of generalized anxiety disorder and a brain tumor, reported an allegation of rape by a family member. Despite this serious incident, the facility did not complete a PTSD assessment following the allegation and failed to create a trauma care plan with specific triggers and interventions. The resident expressed distress and a lack of support services, highlighting the facility's inaction in addressing the resident's trauma. Resident #24, diagnosed with PTSD, bipolar disorder, anxiety, and dementia, did not have a comprehensive trauma-informed care plan that identified specific triggers and interventions. The existing care plan included general interventions such as monitoring sleep and appetite, but lacked personalized strategies to address the resident's PTSD. The social worker acknowledged that a formal assessment and a care plan with specific triggers should have been developed for the resident. Similarly, Resident #26, who has PTSD, depression, and anxiety, also lacked a comprehensive trauma-informed care plan with identified triggers and interventions. The care plan included general interventions like medication administration and monitoring for self-harm, but did not address specific trauma-related triggers. The social worker confirmed that residents with PTSD should have individualized care plans with identified triggers, which was not done for Resident #26.
Failure to Implement Safeguards Following Allegation of Abuse
Penalty
Summary
The facility failed to develop and implement a plan of care to protect a resident and other residents following an allegation of rape. Resident #70, who has a diagnosis of generalized anxiety disorder and moderately impaired cognition, reported being raped by a family member while out of the facility. Despite the ongoing investigation by the District Attorney's office, the facility did not establish safeguards to prevent the alleged perpetrator from visiting the resident or entering the facility. The facility's policy on abuse prevention requires immediate suspension and removal of non-employee individuals accused of abuse pending investigation results. However, the facility did not enforce this policy, allowing the alleged perpetrator to visit the resident and enter the premises without restrictions or supervision. This oversight occurred despite staff awareness of the allegation and the ongoing investigation. Interviews with facility staff, including the Social Worker and Nursing Home Administrator, revealed a lack of communication and action regarding the restriction of the alleged perpetrator's access to the facility. The staff did not implement a plan to protect the resident or other residents, and the alleged perpetrator was observed visiting the facility without any restrictions. This inaction persisted until the surveyor highlighted the deficiency, prompting the facility to acknowledge the oversight.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. For Resident #15, the facility did not provide the necessary adaptive feeding equipment, such as built-up utensils and a nosey cup, during meals as outlined in the care plan. Despite the resident's intact cognition and need for these items due to dysphagia and other health issues, observations over several days showed that the resident was consistently given regular utensils and cups. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for adaptive equipment, with the Director of Nursing unaware that the equipment had been reinstated in the care plan. For Resident #13, the facility failed to maintain the resident's bed in the low position as required by the care plan to prevent falls. Observations over multiple days showed the bed was consistently at a regular height, and staff did not adjust it even when delivering meals. Interviews indicated that some staff were unaware of the requirement to keep the bed in the low position, and the Nurse Unit Manager was not informed of this aspect of the care plan. Additionally, the facility did not perform weekly skin assessments for Resident #13 as ordered by the physician. The resident, who is at high risk for skin breakdown due to various health conditions, had not received a skin assessment since October 2023. This lapse was attributed to a system change in the facility that accidentally deactivated the resident's assessment schedule. Interviews confirmed that the assessments were supposed to auto-populate but failed to do so due to the system error.
Failure to Provide Supervision and Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate supervision and assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident #15, who has diagnoses including dysphagia, dementia, and muscle weakness, was not provided with the necessary supervision and assistance during meals. Despite the care plan indicating the need for continual supervision and hand-over-hand assistance, Resident #15 was observed eating alone in their room on multiple occasions, using their hands instead of utensils. Interviews with staff revealed a lack of adherence to the care plan, with assumptions made about the resident's ability to manage meals independently. Resident #13, with severe cognitive impairment and a history of dysphagia, also did not receive the required supervision and assistance during meals. The care plan specified the need for continual supervision and assistance, yet Resident #13 was repeatedly left alone in their room with meals, leading to instances where they used their hands to eat and did not fully swallow food. Staff interviews confirmed that the resident was supposed to eat in a supervised dining room, but this was not consistently followed, and physician orders for meal supervision were not adhered to. Resident #14, who is cognitively intact but requires assistance for bathing, reported not receiving a shower in over a week, despite being scheduled for showers twice a week. The facility's documentation did not indicate any refusals of care by the resident, and interviews with staff highlighted a lack of proper documentation and follow-up when care was not provided. The Director of Nursing acknowledged the need for multiple attempts to provide care and proper documentation of any refusals, which was not evident in Resident #14's case.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic medications, specifically for two residents, prior to administering these medications. Resident #74, who was admitted with a diagnosis of manic depression, was administered Paxil, an antidepressant, without a signed consent. The resident's medical record did not include the necessary consent documentation, and interviews with the Nurse Unit Manager and the facility Social Worker confirmed that the consent was not completed until after the medication had been administered. The Director of Nurses also acknowledged that consents are required before administering psychotropic medications. Similarly, Resident #81, who has severe cognitive impairment and was diagnosed with depression, adult failure to thrive, and mood disorder, was prescribed Ativan for anxiety without obtaining informed consent. The medical record for this resident also lacked a signed consent for the use of Ativan. Interviews with the Nurse Unit Manager and the facility Social Worker revealed that the consent was not obtained, and the Director of Nurses reiterated the requirement for signed consents prior to medication administration.
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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