Mont Marie Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 36 Lower Westfield Road, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225556
- Inspections on file
- 20
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mont Marie Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Nursing staff failed to properly operate portable oxygen tanks for a resident with CHF, CKD, and diabetes who developed acute shortness of breath and low O2 saturation. One nurse assessed the resident and directed another nurse to obtain portable oxygen from the unit and then from a second unit, but both tanks were reported as appearing empty based on the regulator gauges. Later inspection showed the tanks were not empty, and it was determined that the nurse who retrieved them did not know to use the metal key to fully open the tank valve so the oxygen would flow and the gauge would display an accurate reading, despite having completed required oxygen administration competencies on hire.
A resident's Health Care Agent, acting under an activated proxy, requested copies of the resident's medical records by submitting a signed release and following facility procedures, but did not receive the requested documentation. The facility's records confirmed the requests were made, but there was no evidence the records were provided, and the administrator could not produce documentation showing compliance.
A resident with severe cognitive impairment and multiple medical conditions did not receive assistance from staff in scheduling a podiatry appointment, despite a request from their Health Care Agent and a physician's order. There was no documentation that podiatry services were provided, and the podiatrist's office confirmed no request was received from the facility.
A resident with Parkinson's disease, ulcerative colitis, and an ileostomy did not receive multiple prescribed bowel and other medications within the required timeframes, with doses often given more than an hour late and after meals instead of before as ordered. This failure to follow physician orders and facility policy resulted in difficulties managing the resident's ileostomy output, as confirmed by the DON and the resident's representative.
A resident with Parkinson's disease was administered incorrect dosages of Carbidopa-Levodopa for several days after admission due to a nurse inaccurately transcribing hospital discharge orders during medication reconciliation. The resident received only half the prescribed dose of both immediate and extended release formulations, and the error was not identified until after multiple administrations.
A resident with multiple mental health diagnoses and on Seroquel did not receive EKG monitoring every six months as recommended by the Behavioral Health Nurse Practitioner. The facility failed to ensure timely follow-up EKGs, with a 14-month gap between tests, despite the known risks associated with the medication and the provider's documented recommendations.
Staff serving breakfast on one unit failed to perform required hand hygiene between handling dirty tableware and serving meals to residents. Despite facility policy and prior education, nurses and CNAs were observed serving food and clearing plates without washing hands or using hand sanitizer, and no staff used the available hand washing sink during the meal service.
Surveyors identified that two residents did not have their MDS assessments accurately completed: one resident's edentulous status and loose dentures were not documented, and another resident's unhealed pressure ulcers were omitted from the MDS, despite clinical records and staff interviews confirming these conditions.
Nursing Staff Lacked Competency in Operating Portable Oxygen Tanks
Penalty
Summary
Nursing staff failed to demonstrate competency in setting up and operating portable oxygen equipment for a resident who experienced acute shortness of breath. The facility’s oxygen administration policy required staff to assemble a portable oxygen cylinder and regulator, turn on the oxygen, and then apply the appropriate delivery device. A resident with diagnoses including congestive heart failure, chronic kidney disease, and diabetes reported being unable to breathe while on room air. Nursing assessment found the resident’s oxygen saturation to be low, and a nurse directed another nurse to obtain a portable oxygen tank from the unit’s code cart. The nurse reported that the regulator gauge on that tank showed it was empty, and a second tank obtained from another unit was also reported as appearing empty. Subsequent review and interviews revealed that neither oxygen tank was actually empty. The Staff Development Coordinator later inspected the tanks and stated that if the tank valve was not fully opened with the metal key on top of the tank, the regulator gauge would not accurately display the remaining oxygen and could falsely appear empty. In an interview, the nurse who retrieved the tanks admitted she did not know she needed to twist the top of the oxygen tank with the metal key to turn the oxygen on so that the gauge would show the true amount of oxygen available. Although facility leadership and the Staff Development Coordinator stated that this nurse had completed all required clinical competencies upon hire, including the steps needed to prepare a portable oxygen tank for use, the incident demonstrated that the nurse was unaware of the need to open the tank valve with the key in order to access and administer oxygen to the resident.
Failure to Provide Medical Records to Resident's Health Care Agent
Penalty
Summary
The facility failed to ensure a resident's rights regarding access to medical records were maintained when the resident's Health Care Agent (HCA), whose authority had been activated, requested copies of the resident's medical documentation. The HCA submitted a signed release form and made multiple requests for the records, both in writing and by phone, but did not receive the requested documentation. The facility's Medical Record Request log confirmed that requests were made on two separate occasions, but there was no indication that the records were provided. The resident involved had significant medical conditions, including Alzheimer's Disease, urinary tract infection, urinary retention, a history of falls, congestive heart failure, and malnutrition, and was assessed as severely cognitively impaired. Despite the facility's policy allowing residents or their representatives to obtain copies of records with proper notice and documentation, there was no evidence that the facility fulfilled the HCA's requests. The administrator confirmed that there was no documentation to support that the records had been provided as required.
Failure to Assist with Scheduling Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care for one resident by not assisting in scheduling a podiatry appointment as requested. The facility's policy requires that residents be assisted in making appointments and with transportation to specialists as needed. Documentation showed that the resident's Health Care Agent requested podiatry services upon admission, and a physician's order allowed for a podiatry consult. However, there was no evidence in the clinical record that podiatry services were scheduled or provided. Interviews revealed that the resident had thick and long toenails, and the podiatrist's office confirmed they had not received a request for services from the facility. The DON described the process for scheduling podiatry services but was unable to provide documentation that the process had been followed for this resident. The resident was severely cognitively impaired, dependent on staff for care, and had multiple diagnoses, including Alzheimer's Disease and congestive heart failure.
Failure to Administer Medications Timely for Resident with GI Disorders
Penalty
Summary
Nursing staff failed to administer multiple prescribed medications to a resident with complex gastrointestinal conditions, including Parkinson's disease, ulcerative colitis, and an ileostomy, in accordance with physician orders and professional standards. The medications, which included Diphenoxylate-Atropine, Loperamide HCl, Cholestyramine, and Benefiber, were specifically ordered to be given at set times, often before meals, to manage the resident's loose stools and ileostomy output. Facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified. Audit of medication administration records revealed repeated instances where these medications were given more than an hour late, and in several cases, after meals rather than before as ordered. These delays occurred on multiple dates and involved several scheduled doses, with some medications being administered up to two hours late. The late administration was confirmed by both the medication audit report and the Director of Nursing, who acknowledged that the medications were not given according to the physician's orders. The resident's representative reported that the untimely administration of these medications led to difficulties in managing the consistency and volume of the resident's ileostomy output. The facility's failure to provide timely medication administration did not meet professional standards of nursing care as outlined in facility policy and state regulations, which require nurses to implement prescribed medical regimens and adhere to accepted standards of practice.
Medication Reconciliation Error Leads to Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff incorrectly transcribed the resident's hospital discharge orders for Carbidopa-Levodopa, a medication critical for managing the resident's movement disorder. The hospital discharge summary specified that the resident should receive two tablets of both immediate release and extended release Carbidopa-Levodopa at specified times, but the orders entered into the facility's system only provided for one tablet of each formulation. As a result of this error, the resident received only half the prescribed dose of Carbidopa-Levodopa for multiple days. This discrepancy was identified after the resident reported symptoms to their representative, who then inquired about the medication regimen. Review of the Medication Administration Record confirmed that the resident had received the incorrect dosage on several occasions, both for the immediate release and extended release formulations. Interviews with facility staff, including the nurse responsible for the admission and the nursing supervisor, confirmed that the medication reconciliation process was not followed accurately. The nurse failed to correctly transcribe the hospital discharge medication list, and the error was not identified until after the resident had already received the incorrect dosages. The Director of Nursing acknowledged that the orders were entered incorrectly and that the resident was administered the wrong dose until the issue was corrected.
Failure to Implement Behavioral Health EKG Monitoring Recommendations
Penalty
Summary
The facility failed to implement the Behavioral Health Care Team's recommendation for a resident diagnosed with Parkinson's Disease, Obsessive Compulsive Disorder, and Dementia with psychotic disturbance. The resident was prescribed Seroquel, an antipsychotic medication known to have the potential to cause heart arrhythmias, which requires regular monitoring through an EKG to check for changes in the QTc interval. The Behavioral Health Nurse Practitioner recommended that an EKG be performed every six months to monitor for these potential side effects. Despite this recommendation, the resident's medical record showed that after a baseline EKG was completed prior to admission, the next EKG was not performed until 14 months later, rather than the recommended six-month interval. The Director of Nursing confirmed that a physician order for a follow-up EKG should have been implemented after the recommendation was made, but this did not occur, resulting in a failure to provide the appropriate monitoring for the resident while on Seroquel.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
During a breakfast meal observation on the 3rd Floor Unit, seven staff members, including nurses, CNAs, and a dietary aide, were involved in serving meals to ten residents in the dining room. The staff were observed serving food, pouring beverages, and clearing dirty tableware without performing appropriate hand hygiene between these tasks. Specifically, one CNA was seen handling dirty plates, cups, and utensils with bare hands and did not perform hand hygiene before serving other residents. Although a hand washing sink was available behind the steam table, none of the staff were observed using it for hand hygiene during the meal service. The facility's policy requires all food and nutrition services staff, including nursing personnel, to wash their hands before serving food and after handling soiled plates and food waste. However, staff did not adhere to these guidelines during the observed meal service. Interviews with staff and the Director of Nursing confirmed that the expectation is for staff to perform hand hygiene between serving each resident, and that staff have previously been educated on these practices. Despite this, no staff were observed following the required hand hygiene protocols during the meal service.
Inaccurate MDS Assessments for Dental Status and Pressure Ulcers
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies in the documentation of dental status and pressure ulcer presence. For one resident, who was admitted with cachexia, dysphagia, and malignant neoplasm, the clinical record and dental consult indicated the presence of full upper and lower dentures, both of which were loose fitting. The resident was edentulous and only wore the upper dentures for eating, while the lower dentures were never worn due to poor fit. Despite these findings, the MDS assessments consistently failed to document the resident's edentulous status and the presence of loose dentures, instead indicating no dentures or dental concerns. Interviews with staff confirmed the resident's dental status and the inaccuracies in the MDS coding. For another resident with diagnoses including diabetes mellitus type II, acute kidney failure, and dependence on renal dialysis, the care plan and treatment records showed the presence of an unstageable right heel pressure injury and a stage 2 pressure injury on the left foot. Wound care treatments were documented for both sites during the relevant observation period. However, the most recent MDS assessment did not reflect the presence of any unhealed pressure ulcers, contrary to the clinical documentation and wound assessment report. The MDS Coordinator acknowledged that the assessment should have been coded to indicate the pressure ulcers present during the look-back period. These deficiencies were identified through record review, direct observation, and staff interviews, which revealed discrepancies between the residents' clinical conditions and the information recorded in the MDS assessments. The failure to accurately code for dental status and pressure ulcers resulted in incomplete and inaccurate resident assessments.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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