Mission Care At Holyoke
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 35 Holy Family Road, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225480
- Inspections on file
- 21
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Mission Care At Holyoke during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple comorbidities was found with a new bruise near the right eye, but nursing staff failed to notify the provider as required by facility policy. Instead, internal incident documentation was completed and the Unit Manager was informed, but neither the provider nor the DON were notified. The resident was later hospitalized, where a skull fracture and subarachnoid hemorrhage were discovered. The provider confirmed they were not informed of the injury, and the DON acknowledged the lapse in required notification.
A resident with multiple medical conditions was found with a bruise of unknown origin above the right eyebrow. Nursing staff documented and assessed the injury but did not recognize the requirement to report it to DPH within two hours, resulting in a six-day delay before the incident was reported, contrary to facility policy.
Two residents with ESRD did not have pharmacist recommendations addressed in a timely manner. One continued to receive a multivitamin containing Vitamin A and E, which was not recommended, for several months after the pharmacist and physician agreed it should be discontinued. Another resident continued to receive Acetaminophen-Codeine, which should be avoided in dialysis patients, because the medication review was not promptly addressed due to communication lapses.
Surveyors identified multiple failures in hand hygiene, manual ware washing, and cleaning practices by dietary and housekeeping staff, including improper glove use, incorrect utensil sanitization, and unclean kitchenettes with food debris and spills. Staff interviews confirmed lack of training and adherence to protocols, and cleaning logs showed missed or undocumented cleaning in resident care unit kitchenettes.
Staff failed to perform hand hygiene before and after distributing meal trays, handling both clean and dirty trays, and entering and exiting resident rooms. Alcohol-based hand sanitizer was available but not used as required, and gloves were worn in the hallway against policy. Staff interviews confirmed these lapses in infection control practices.
A resident with Alzheimer's Disease, who was dependent on staff for oral hygiene and had documented dental issues, did not receive routine dental care despite a signed consent and care plan. Dental services were not scheduled after an insurance issue was resolved, and staff responsible for referrals did not follow up, resulting in the resident not receiving needed dental care.
A resident with severe cognitive impairment and an activated HCP was not provided with effective discharge planning to facilitate transfer to a SNF closer to family, despite repeated requests and documented hardship. The facility failed to make or document ongoing referrals for alternate placement, and staff acknowledged that no further efforts had been made for several months.
A resident with severe cognitive impairment and dependent on staff for dressing was left uncovered in bed with underwear visible from the hallway. Multiple staff, including CNAs and a nurse, observed the situation but did not intervene to cover the resident, despite facility expectations to do so.
A resident with a G-tube for severe dysphagia was found in a room where the feeding pump, IV pole, headboard, wall, and corkboard had dried brownish splatter marks that were not cleaned over several days. Staff interviews revealed confusion about cleaning responsibilities, and the facility's cleaning policy was not followed, resulting in an unclean and non-homelike environment.
A resident with PTSD and Personality Disorder experienced a significant decline in mental health, including new homicidal and suicidal ideation and the initiation of psychotropic medications, but the facility failed to notify the PASRR Office for a required Resident Review as mandated by policy and regulation.
Two residents requiring assistance with eating and prescribed thickened liquids due to dysphagia were not provided with the correct liquid consistencies during meals. Staff failed to follow speech therapy recommendations and physician orders, did not use proper feeding techniques, and did not recognize or report signs of aspiration, resulting in both residents being put at risk.
A resident with significant weight loss and a physician's order for health shakes with meals did not receive the supplement with breakfast due to a failure to update the dietary slip and communicate the order to the kitchen. Staff and the resident confirmed the omission, and the dietician noted the supplement was only provided at lunch and dinner, not breakfast.
A resident with severe cognitive impairment and dysphagia, dependent on staff for eating and prescribed a pureed diet, was given a peanut butter and jelly sandwich and left unsupervised by a CNA who did not check the care plan. The resident was later found unresponsive and pronounced dead. Staff interviews confirmed the resident should not have received the sandwich or been left alone, and the care plan interventions were not followed.
A resident with dysphagia and severe cognitive impairment, who required a pureed diet and one-on-one staff assistance while eating, was given a peanut butter and jelly sandwich by a CNA who did not check the resident's diet order or care card. The CNA left the resident unsupervised, and the resident was later found unresponsive after aspirating on the sandwich. Staff interviews and documentation confirmed the resident's need for supervision and dietary restrictions, which were not followed, resulting in the resident's death.
A Maintenance Assistant in an LTC facility hugged and kissed a cognitively intact resident without consent, making the resident uncomfortable and triggering their PTSD. The resident, with a history of anxiety and PTSD, reported the incident, leading to the Maintenance Assistant's admission of inappropriate behavior and subsequent termination.
The facility failed to ensure staff adhered to infection control standards during a COVID-19 outbreak. Staff did not wear required PPE when caring for COVID-19 positive residents and failed to perform proper hand hygiene between resident contacts. These lapses were observed on two units and confirmed through staff interviews.
The facility failed to implement its smoking policy for a resident who was hospitalized on two occasions. Despite the policy requiring smoking evaluations upon re-admission, the resident's medical record showed no documentation of such evaluations. Interviews with staff confirmed that these evaluations should have been completed.
The facility failed to provide proper respiratory care for a resident with COPD, Chronic Respiratory Failure, and OSA. The staff did not clean or store the resident's BiPAP mask as required, and the oxygen concentrator filter was found dirty and unmaintained. These lapses placed the resident at risk for infections and impaired oxygen delivery.
The facility failed to provide appropriate dialysis care for a resident with ESRD by not consistently communicating nurse assessments, applying Lidocaine cream, or removing pressure dressings within 24 hours, leading to potential complications and discomfort for the resident.
A resident received an excessive dosage of Abilify due to the facility staff's failure to discontinue a previous 20 mg order before administering a new 25 mg order, resulting in a total daily dose of 45 mg, which exceeded the recommended maximum of 30 mg.
The facility failed to accurately execute Advance Directives for two residents. For one resident, the MOLST form was signed by the HCP without the resident being deemed incapable of making their own medical decisions. Similarly, for another resident, the MOLST form was signed by the HCP without evidence of the resident being deemed incapable by a medical professional.
Failure to Notify Provider of New Bruise of Unknown Origin
Penalty
Summary
Nursing staff failed to notify the provider when a cognitively impaired resident, who was dependent on staff for care, was observed with a new bruise of unknown origin near the right eye. The facility's policy required that the physician be notified of any unexpected or substantial change in a resident's condition, including new injuries. Despite this, when the bruise was discovered by a nurse during morning rounds, the nurse only notified the Unit Manager and completed internal incident documentation, but did not contact the physician or the Director of Nursing as required. The Unit Manager, after being informed by the nurse, assessed the bruise and instructed the nurse to complete the necessary incident and skin/bruise reports, but also did not notify the provider or the Director of Nursing. Documentation in the resident's progress notes over several days confirmed the presence of the bruise, but there was no evidence that the provider was informed at any point during this period. The resident, who had diagnoses including vascular dementia, osteoporosis, and a history of stroke, was unable to communicate how the injury occurred. Subsequently, the resident was transferred to the hospital for evaluation of altered mental status and self-removal of a urinary catheter. At the hospital, imaging revealed a right temporal bone fracture and subarachnoid hemorrhage, with no reported trauma. The provider confirmed during an interview that they had not been notified of the bruise and stated that such notification was necessary, as it could have warranted immediate evaluation. The Director of Nursing also acknowledged that the required notifications had not been made when the bruise was first observed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who had diagnoses including vascular dementia, depression, osteoporosis, history of stroke, and aphasia, was found by a nurse to have a red-purple, non-tender bruise above the right eyebrow during routine rounds. The nurse did not recall any prior documentation or report of the bruise and immediately notified the Unit Manager, who assisted in assessing the injury and initiating an incident report. Despite these actions, neither the nurse nor the Unit Manager was aware that such an injury of unknown origin required immediate reporting to DPH. The facility's policy mandates that any allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown source must be reported to DPH immediately, but not later than two hours after discovery if it involves abuse or serious bodily injury. In this case, the injury was first identified and documented by nursing staff, but the required report to DPH was not made until six days later, after the hospital notified the facility of additional findings, including a non-displaced fracture and subarachnoid hemorrhage. Interviews with staff revealed a lack of awareness regarding the reporting requirements for injuries of unknown origin. The Director of Nursing confirmed that the facility's policy was not followed, as the nursing staff did not notify her immediately about the injury, and the report to DPH was significantly delayed. The deficiency centers on the failure to recognize and act upon the obligation to report the injury of unknown origin within the mandated timeframe, despite the facility's established policies and procedures.
Failure to Timely Implement Pharmacist Recommendations for Residents with ESRD
Penalty
Summary
The facility failed to implement and address licensed pharmacist recommendations in a timely manner for two residents with end stage renal disease (ESRD). For one resident, the pharmacist recommended discontinuing a multivitamin containing Vitamin A and E, which are not advised for individuals with ESRD, and switching to Nephrocaps. The physician agreed with this recommendation, but the order to discontinue the multivitamin and initiate Nephrocaps was not transcribed or implemented until several months later, resulting in the resident continuing to receive the inappropriate multivitamin for an extended period. For another resident, the pharmacist recommended evaluating the use of Acetaminophen-Codeine, a medication advised to be avoided in dialysis patients, and suggested considering an alternative pain management option. The medication regimen review (MRR) was not addressed by the provider, and the resident continued to receive Acetaminophen-Codeine as ordered. The MRRs for this resident were not reviewed or acted upon until much later due to a breakdown in communication, as the MRRs were sent to a supervisor who was on leave and not seen by facility staff until after the deficiency was identified. Facility policy required that prescribers act upon drug regimen review recommendations within 7-14 days and document their response. In both cases, these requirements were not met, resulting in prolonged administration of medications that were not recommended for residents with ESRD. The failure to timely implement pharmacist recommendations and ensure proper documentation led to the identified deficiencies.
Failure to Maintain Sanitation and Food Handling Standards in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen and in all three resident care unit kitchenettes. Surveyors observed multiple instances where dietary staff did not maintain appropriate hand hygiene while preparing and serving meals. Staff were seen touching their faces, masks, and beard guards with gloved hands and then continuing to handle food and clean trays without changing gloves or washing hands as required by facility policy. Interviews with staff confirmed a lack of adherence to hand hygiene protocols, and staff acknowledged the importance of these practices to prevent food contamination. In the main kitchen, improper manual ware washing procedures were observed. Dietary aides did not follow the correct sequence for washing, rinsing, and sanitizing utensils, often rinsing sanitized utensils over the garbage disposal or wiping them with paper towels instead of air drying. Some staff were unaware of the required submersion time in sanitizer and had not received proper training on the three-compartment sink process. Additionally, countertops used for food preparation were cleaned with soapy water from the wash sink containing food debris, rather than with sanitizer solution, increasing the risk of cross-contamination. The kitchenettes on all three floors were found to be inadequately cleaned, with dried food splatter, liquid spills, debris, and improper storage of utensils and food items. Cleaning logs indicated missed or undocumented cleaning on several days. Observations included open ceiling tiles with exposed insulation, cracked ice chests, and food and beverage spills, all of which were acknowledged by the Food Service Director and Housekeeping Supervisor as risks for contamination and pest infestation. Housekeeping staff confirmed responsibility for cleaning but failed to consistently document or perform required cleaning tasks.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 3rd Floor Unit failed to adhere to infection control standards during lunch meal service. Four staff members, including two nurses and two CNAs, were observed removing meal trays from the meal truck and distributing them to residents without performing hand hygiene before or after entering resident rooms. Staff were seen entering rooms, handling bedside tables, and positioning trays for residents, then exiting rooms and continuing to distribute trays without using the alcohol-based hand sanitizer available in the hallway. Additionally, staff were observed handling both clean and dirty meal trays without performing hand hygiene in between, and one nurse was seen exiting a resident's room wearing gloves, which is against facility policy for hallway conduct. Interviews with staff confirmed that the expectation was to use alcohol-based hand sanitizer before entering and after exiting resident rooms, and that gloves should not be worn in the hallway. Staff acknowledged forgetting to perform hand hygiene and not following the established procedures. The Infection Control Nurse reiterated the facility's policy and expectations regarding hand hygiene and glove use, confirming that the observed practices did not align with infection prevention protocols.
Failure to Provide Routine Dental Services After Consent and Care Plan Initiation
Penalty
Summary
A resident with Alzheimer's Disease was admitted to the facility in April 2023 and was noted to have broken natural teeth and cavities upon admission. The resident's representative signed a request for dental services in May 2023, and a physician's order authorized dental, vision, auditory, podiatry, and wound consults. The resident's care plan included coordination for dental care due to the observed dental issues. The Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, fully dependent on staff for oral hygiene, and had obvious dental problems. Despite the signed consent and care plan directives, the facility failed to schedule and provide routine dental services for the resident. According to interviews, the medical records staff member responsible for dental referrals did not arrange for dental care after an initial insurance issue was resolved approximately six months post-admission. The administrator confirmed that the resident should have received dental services but was not aware that the services had not been provided, and no alternative arrangements were made.
Failure to Uphold Resident Rights in Discharge Planning
Penalty
Summary
The facility failed to uphold resident rights for one resident by not implementing an effective discharge planning process that considered the goals of the resident's Health Care Proxy (HCP). The resident, who had severe cognitive impairment due to dementia and other psychiatric diagnoses, had an activated HCP, with a family member designated to make decisions. The family's stated goal was to have the resident transferred to a skilled nursing facility closer to them, as the current location posed a significant financial and logistical burden for visits. Documentation in the resident's care plan and social services notes indicated that the facility was aware of the family's preference and the hardship caused by the distance. The care plan included interventions for providing information and referrals to assist with the transfer. However, after an initial referral attempt in early 2025, there was no evidence of further referrals or follow-up calls to other facilities for placement. The social worker acknowledged that no additional referrals had been made in the past six months, despite ongoing requests and discussions with the family. Interviews with the family member and facility staff confirmed that the facility did not consistently pursue alternate placement options or maintain documentation of referral efforts. The administrator and social worker both recognized that more should have been done to assist with the transfer, especially given the family's repeated requests. The facility was unable to provide documentation of referrals or follow-up actions to the survey team at the time of the survey exit.
Failure to Maintain Resident Dignity by Not Covering Unclothed Resident
Penalty
Summary
Staff failed to promote the dignity of a resident with severe cognitive impairment, who was dependent on staff for lower body dressing, by not intervening when the resident was observed uncovered in bed with underwear briefs visible from the hallway. Multiple staff members, including two CNAs and a nurse, walked past the resident's room, looked in, and did not take action to cover the resident, despite being able to see that the resident was uncovered. The resident had diagnoses of dementia and neurosyphilis and was known to frequently remove covers. Staff interviewed at the time acknowledged that the expectation was to cover or offer to cover residents observed to be uncovered, regardless of the resident's tendency to remove blankets. The deficiency was identified through direct observation, interviews, and record review.
Failure to Maintain Clean and Homelike Environment for G-Tube Dependent Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident who was dependent on a G-tube for nutrition due to severe dysphagia and other medical conditions. Multiple observations revealed that the resident's room, specifically the area around the G-tube feeding equipment, was not properly cleaned. The EnteraFlo pump, IV pole, corkboard, wall, and headboard near the resident's bed all had dried brownish colored splatter marks, indicating a lack of cleaning following a spill of nutritional supplement. The facility's policy required spot cleaning of vertical surfaces and IV poles, but these areas remained visibly soiled over several days. Interviews with nursing staff, housekeeping, and the administrator confirmed that the soiled areas should have been cleaned either immediately by staff or by housekeeping, but this was not done. There was also confusion among staff regarding responsibility for cleaning the G-tube pump and surrounding areas. The deficiency was identified through direct observation, record review, and staff interviews, all of which confirmed that the environment was not maintained in accordance with facility policy and resident rights.
Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Personality Disorder, but the initial PASRR screening did not document any mental illness or disorder, and a Level II PASRR evaluation was not indicated at that time. Upon admission, there were no psychotropic medications ordered for the resident. Over the following months, the resident exhibited escalating behavioral and psychiatric symptoms, including aggressive behavior, refusal of medications, physical altercations with residents and staff, sexually inappropriate behavior, and exit-seeking. The resident also began expressing both homicidal and suicidal ideation, including specific threats to harm themselves and others. Psychiatric assessments documented these changes, and the resident was eventually started on psychotropic medications, including Lamotrigine and later Sertraline, to address mood instability and depressive symptoms. Despite these significant changes in mental status and the initiation of psychotropic medication, the facility did not refer the resident to the PASRR Office for a Resident Review as required by policy and regulation. Interviews with facility staff confirmed that no referral was made, even though the social worker acknowledged that the resident's change in behavior and need for medication constituted a significant change in mental condition that should have triggered a PASRR Resident Review.
Failure to Provide Safe Feeding Assistance and Ordered Liquid Consistencies
Penalty
Summary
The facility failed to provide safe feeding assistance for two residents who required help with eating, resulting in both being put at risk for aspiration. For one resident with severe cognitive impairment, dysphagia, and a recent diagnosis of aspiration pneumonia, staff did not follow the speech therapist's recommendations for honey-thick liquids to be given by teaspoon. During a meal observation, the certified nursing assistant (CNA) provided large sips of milk directly from a cup, did not verify the correct liquid consistency, and gave multiple heaping spoonfuls of food in rapid succession without ensuring the resident had swallowed each bite. The CNA also mixed applesauce with other foods without authorization and failed to recognize or report signs of aspiration, such as coughing and gulping, during the meal. Another resident, also dependent on staff for eating and with a history of recurrent pneumonia and dysphagia, was not provided with the ordered nectar-thick beverages during a breakfast meal. The CNA assisting this resident failed to add thickener to the cranberry juice and was unsure if thickener had been added to other beverages. The CNA admitted to forgetting to thicken the cranberry juice and only realized the omission after the meal was completed. The nurse and nurse consultant confirmed that staff are responsible for ensuring liquids are thickened according to physician orders and acknowledged that providing incorrect liquid consistency could pose a risk for aspiration. Both incidents were observed and confirmed through interviews and record reviews. The facility's policies required staff to check diet slips, provide appropriate food and liquid consistencies, and monitor for signs of aspiration. However, these protocols were not followed, and staff demonstrated a lack of understanding of the specific feeding techniques and precautions required for residents with dysphagia. The deficiencies were directly related to staff actions and inactions during meal assistance, as well as a lack of adherence to individualized care plans and physician orders.
Failure to Provide Ordered Nutritional Supplement at Breakfast
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, dementia, significant weight loss, and a therapeutic diet order did not receive prescribed health shakes with breakfast as ordered by the physician. The resident had experienced a 13.5-pound weight loss over four months, and the care plan included the addition of health shakes to increase calorie intake. Despite this, observations on multiple occasions showed that the health shake was not present on the resident's breakfast tray, and the resident confirmed not receiving the supplement at breakfast. Interviews with nursing staff and a CNA revealed that the health shake order was not reflected on the resident's dietary slip for breakfast, although it was present for lunch and dinner. Staff indicated that the process for ensuring supplements are provided involves entering the order into the electronic medical record and completing a Diet Requisition and Dietician Communication Form, which should be submitted to the kitchen. However, this process was not followed for the breakfast meal, resulting in the omission of the health shake. The dietician confirmed that the recommendation for health shakes had been made due to the resident's weight loss, but the kitchen had only included the supplement for lunch and dinner, not breakfast. The failure to update the dietary slip and communicate the order to the kitchen led to the resident not receiving the prescribed nutritional supplement with breakfast, as required by the care plan and physician's order.
Failure to Follow Care Plan for Resident with Dysphagia Results in Fatal Incident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, diagnosed with dementia, dysphagia, and schizophrenia, was not provided care in accordance with their established care plan. The resident was dependent on staff for eating and required a pureed diet due to difficulty swallowing, as documented in the care plan, physician's orders, and CNA care card. The care plan also specified that the resident needed one-on-one staff assistance during meals and snacks to ensure safety and prevent aspiration. On the evening of the incident, a CNA delivered a peanut butter and jelly sandwich to the resident as an evening snack, which was not consistent with the prescribed pureed diet. The CNA did not check the resident's care card for dietary restrictions or required supervision level before providing the snack. After delivering the sandwich, the CNA left the resident unattended in their room and continued distributing snacks to other residents. The resident was later found unresponsive and without a pulse, and was subsequently pronounced dead at the facility. Interviews with facility staff, including the rehabilitation director, dietician, and nursing supervisor, confirmed that the resident should not have been given a sandwich or left unsupervised while eating. The failure to follow the care plan interventions, including providing the correct food consistency and required staff assistance, directly led to the deficiency identified during the survey.
Failure to Provide Required Supervision and Diet Consistency Results in Resident Death
Penalty
Summary
A resident with diagnoses including dysphagia, dementia with agitation, and schizophrenia was on a physician-ordered pureed diet (NDD1) and was dependent on staff for eating due to severe cognitive impairment and hand tremors. The resident's care plan specified the need for one-on-one staff assistance during meals and snacks, as well as strict adherence to the prescribed pureed diet to prevent aspiration. The resident's Minimum Data Set (MDS) and care plans consistently documented the need for dependent-level assistance and close supervision while eating. On the evening of the incident, a Certified Nurse Aide (CNA) delivered a peanut butter and jelly sandwich to the resident as a snack, without checking the resident's diet orders or care card for required assistance. The CNA did not remain with the resident while he ate and left him unsupervised in his room. Approximately fifteen minutes later, the resident was found unresponsive, and resuscitation efforts were unsuccessful. Witness statements and interviews confirmed that the resident was typically provided with pudding or yogurt for snacks and that staff were aware of the resident's dietary restrictions and need for supervision. Interviews with facility staff, including the Speech Language Pathologist, Dietician, and Director of Nursing, confirmed that the resident required a pureed diet and one-on-one supervision during meals and snacks due to his dysphagia and cognitive impairment. The CNA involved admitted to not checking the care card or diet order before providing the snack and acknowledged leaving the resident unattended. Facility policies required staff to follow diet orders and provide the necessary level of assistance, which was not done in this case, resulting in the resident's death after aspirating on the sandwich.
Inappropriate Conduct by Maintenance Assistant
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as required by their policy on Resident Rights and Responsibilities. On a specific day, a Maintenance Assistant hugged and kissed a cognitively intact resident without consent, which made the resident feel uncomfortable and triggered their PTSD. The resident, who had a history of anxiety disorder, PTSD, major depressive disorder with psychotic symptoms, and schizoaffective disorder, reported feeling uncomfortable and afraid of the incident recurring. The Maintenance Assistant admitted to the inappropriate behavior, stating that he hugged and kissed the resident to comfort them after they expressed feeling depressed. The incident was reported to the facility's Social Worker and Administrator, and the resident expressed fear and reluctance to discuss the details. The Maintenance Assistant acknowledged that his actions were wrong and that he had crossed a line, leading to his suspension and eventual termination.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for transmission-based precautions for two residents and on two units during a COVID-19 outbreak. Specifically, on Unit One, staff did not wear the required personal protective equipment (PPE) when caring for COVID-19 positive residents. For instance, a CNA entered a resident's room with only a surgical mask instead of the required N95 mask. Additionally, another staff member entered a different resident's room without the necessary eye protection. Both instances were observed despite clear signage and available PPE supplies outside the rooms, and staff acknowledged their failure to comply with the PPE requirements during interviews immediately following the observations. On Unit Three, staff failed to perform proper hand hygiene after caring for a COVID-19 positive resident and between contacts with multiple residents. A CNA was observed exiting a COVID-19 positive resident's room, doffing PPE, and then entering another resident's room without performing hand hygiene. This CNA admitted to not following the required hand hygiene protocols after removing PPE and before interacting with another resident. The facility's policy on hand hygiene clearly indicated the need for hand hygiene after removing gloves and before entering and exiting residents' rooms, which was not adhered to in this case. The deficiencies were observed during a survey, and interviews with staff confirmed the lapses in following the facility's infection control policies. The facility's policies on droplet and contact precautions, as well as hand hygiene, were not followed, leading to potential risks of contamination and spread of infection during the COVID-19 outbreak. The staff's failure to use appropriate PPE and perform hand hygiene as required by the facility's policies were the primary actions leading to the identified deficiencies.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its smoking policy for one resident out of a sample of 24. Specifically, the facility did not complete re-admission smoking evaluations for a resident who was hospitalized on two occasions. The facility's policy requires smoking evaluations upon admission, re-admission, and after significant changes in resident status. However, the resident's medical record showed no documentation of smoking evaluations upon their return from the hospital on two separate dates. The resident in question was admitted to the facility with diagnoses including dementia with severe mood disturbance and a history of traumatic brain injury. Despite being identified as a smoker and having a care plan that included smoking evaluations, the facility did not perform these evaluations after the resident's hospitalizations. Interviews with staff confirmed that smoking evaluations should have been completed per facility policy, but they were not done in this case.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, and Obstructive Sleep Apnea (OSA). The staff did not implement a schedule for cleaning and storing the resident's BiPAP mask, which was observed multiple times laying face down on the bed without a protective bag. The resident reported that the BiPAP mask had never been cleaned by the staff, and the mask was found with dried yellow and white debris inside it. Additionally, the storage bag for the BiPAP mask was dirty and undated, indicating it had not been changed as required. The facility also failed to clean and maintain the resident's oxygen concentrator filter according to professional standards. The oxygen concentrator filter was observed to be coated with a thick, gray, fibrous layer of dust. The resident's oxygen concentrator was connected to a nasal cannula, and the dirty filter posed a risk of impaired oxygen delivery and equipment malfunction. The IC Nurse confirmed that the filter was dirty and expressed concern about the air quality the resident was inhaling. The IC Nurse also mentioned that a representative from the oxygen and respiratory supply company indicated that a dirty filter could cause the concentrator to overheat and shut off, stopping the oxygen flow to the resident. Interviews with the nursing staff revealed that the night shift nurse was responsible for cleaning the oxygen concentrator filters weekly, but this task had not been performed. The IC Nurse confirmed that the nursing staff was responsible for cleaning the resident's BiPAP mask and oxygen concentrator filter, but these tasks were not being carried out. The failure to adhere to the facility's policy on respiratory equipment maintenance placed the resident at risk for nosocomial infections and impaired respiratory function.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with End Stage Renal Disease (ESRD). The facility did not consistently communicate the nurse's assessment of the resident prior to dialysis, apply EMLA (Lidocaine) cream to the dialysis access site to prevent pain, or implement the dialysis center's recommendations to remove pressure dressings within 24 hours to prevent clotting of the dialysis access site. These failures were observed and documented multiple times, with the dialysis center repeatedly noting the lack of communication and the presence of pressure dressings beyond the recommended time frame. The resident, who was cognitively intact, had specific physician orders for dialysis treatments and the application of Lidocaine cream to the fistula site. Despite these orders, the facility's nurses often left the pressure dressings on the resident's arm for more than 24 hours, citing concerns about excessive bleeding due to the resident's blood-thinning medication. This practice was contrary to the dialysis center's instructions and led to indentations and deep pits on the resident's arm, as well as a scant amount of bleeding observed during a surveyor's visit. Interviews with the facility's staff, including the Unit Manager and Director of Nurses, revealed a lack of proper communication and adherence to the dialysis center's guidelines. The staff admitted to not consistently completing the Dialysis Communication Form and not removing the pressure dressings in a timely manner. The Director of Nurses acknowledged that a proper assessment of the dialysis site for infection or complications could not be conducted with the pressure dressing in place, highlighting a significant communication issue between the dialysis facility and the nursing facility.
Failure to Discontinue Previous Medication Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the staff did not discontinue an order for a 20 mg dose of Abilify before administering a newly ordered 25 mg dose, resulting in the resident receiving an excessive dosage of 45 mg daily. This dosage exceeded the recommended maximum of 30 mg daily. The resident, who was admitted with a diagnosis of Schizophrenia, received both doses from March 6, 2024, through March 10, 2024, due to a transcription error by a nurse who was distracted and forgot to discontinue the old order. The error was discovered by the Unit Manager after reviewing a Consultant Pharmacist's recommendation and clarifying the order with the Psychiatric Nurse Practitioner. The Unit Manager found that the resident's chart, Medication Administration Record (MAR), and Nursing Progress Notes indicated the resident had been receiving both doses. The nurse responsible for the error was unavailable for an interview during the survey, but it was confirmed that the resident should have only been taking a 25 mg daily dose of Abilify.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for two residents, specifically regarding the completion of the MOLST forms. For Resident #30, who was admitted with diagnoses including Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Bipolar Disorder, and Delusional Disorder, the MOLST form was signed by the Health Care Proxy (HCP) on 8/9/23 without the resident being deemed incapable of making their own medical decisions by a medical professional. There was no documentation indicating that the resident was involved in the decision-making process for the MOLST form. The Social Workers confirmed that the HCP had not been activated until January 2024, meaning the HCP did not have the authority to complete the MOLST form at the time it was signed. Similarly, for Resident #79, who was admitted with diagnoses including Dementia and catatonic disorder, the MOLST form was signed by the HCP on 7/17/23. The clinical record did not indicate that the resident had been deemed by a Physician or Nurse Practitioner as lacking the capacity to make their own health care decisions. The Social Worker confirmed that there was no evidence of the HCP being activated by a medical professional, and thus the HCP should not have signed the MOLST form. These actions led to the deficiency in accurately executing Advance Directives for the residents involved.
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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