Mount Carmel Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenox, Massachusetts.
- Location
- 320 Pittsfield Road, Lenox, Massachusetts 01240
- CMS Provider Number
- 225581
- Inspections on file
- 18
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mount Carmel Care Center during CMS and state inspections, most recent first.
The facility failed to provide timely assistance with bedpan use for a resident at risk for pressure ulcers, leading to the development of a new ulcer. Additionally, the facility did not complete weekly skin assessments for another resident, resulting in a Stage 2 pressure ulcer that worsened over time. Staffing issues and delayed response times contributed to these deficiencies.
The facility failed to ensure sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with toileting and personal care. Residents reported long wait times, especially on weekends and night shifts, leading to episodes of incontinence and unmet needs. Staff interviews confirmed the challenges posed by insufficient staffing levels.
The facility failed to ensure that six nurses had the necessary competencies and certification to provide appropriate CVAD care for a resident receiving IV antibiotics for a left hip infection. The facility lacked a system to verify the competencies of nurses, leading to a significant lapse in resident care.
The facility failed to ensure a resident's privacy and dignity during personal care by not providing appropriate clothing or covering while transporting the resident to and from the shower. The resident's private areas were exposed, and staff confirmed that a blanket or towel should have been used.
A resident on anticoagulant therapy was found bleeding from the left index finger, but the facility failed to notify the physician and resident representative as required by policy. The incident was not investigated or documented properly, and the Director of Nurses was unaware until informed by the surveyor.
The facility failed to accurately code a resident's pressure injury in the MDS Assessment. The resident, admitted with Dementia and Diabetes, developed a Stage 2 pressure injury that was not resolved for over a year. The MDS Nurse confirmed the coding error during an interview.
The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident did not receive proper weekly skin assessments or monitoring of their CVAD catheter site, while another resident did not have weekly skin assessments or a Nurse Practitioner's recommendation for edema management implemented. These deficiencies were confirmed through record reviews, observations, and staff interviews.
The facility failed to investigate and implement interventions for accident/hazard incidents for two residents. One resident with severe cognitive impairment had a new skin area on their left index finger that was not properly investigated or treated. Another resident, who was cognitively intact, developed a pressure injury on their right sacrum after being on a bedpan for too long, but no investigation or changes to their care plan were made.
The facility failed to perform a trauma assessment on admission and develop a care plan for a resident with PTSD. Despite the resident being cognitively intact and having a PTSD diagnosis, no trauma assessment was completed, and no care plan was in place to address potential triggers for re-traumatization, as required by the facility's policy.
The facility failed to ensure an accurate accounting of Lorazepam (Ativan) in the controlled substance accountability record book. An opened syringe with 15cc remaining was found in an unlocked controlled substances lock box and was not recorded as required. The DON confirmed that all controlled substances should be counted and recorded by two nurses at the beginning and end of each shift.
The facility failed to monitor for side effects and adverse reactions to anticoagulant medication for a resident with Pulmonary Embolism and Atrial Fibrillation. The required monitoring was not documented in the resident's clinical record or Medication Administration Records (MARs). A nurse confirmed that the monitoring was not done as required.
The facility failed to ensure that a PRN psychotropic medication, Valium, was limited to 14 days and reviewed by the Physician for continued use for a resident with Alzheimer's disease. The medication was administered multiple times without documented evidence of reassessment by the Physician.
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented and adhered to by staff for two residents, leading to potential infection control issues. Staff members did not consistently wear gowns and gloves during high-contact care activities, despite the requirements outlined in the facility's EBP policy.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide timely assistance with bedpan use for Resident #57, who was at increased risk for pressure ulcers. Despite being cognitively intact and able to request assistance, the resident reported waiting for up to an hour for staff to respond to call lights, especially during night shifts when staffing was low. This delay in assistance led to the development of a new pressure ulcer on the resident's sacrum, which was identified on 1/18/24. The wound consultant suspected the ulcer was caused by prolonged pressure from the bedpan, and the facility did not conduct an investigation or incident report when the ulcer was identified. For Resident #15, the facility failed to complete weekly skin assessments as ordered by the physician. The resident, who had a history of dementia, diabetes, hypertension, and obesity, was at risk for pressure ulcers and had a Stage 2 pressure ulcer that was not identified in a timely manner. The facility missed several weekly skin assessments, including one on 11/20/23, which could have potentially identified the pressure ulcer at an earlier stage. The resident's pressure ulcer worsened over time, indicating a lack of consistent monitoring and timely intervention. The facility's policy on wound and skin care emphasized the importance of regular skin assessments and timely interventions to prevent and manage pressure ulcers. However, the facility did not adhere to these protocols, resulting in the development and worsening of pressure ulcers for the two residents. Interviews with staff and residents highlighted issues with staffing levels and response times, which contributed to the deficiencies in care.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and inadequate assistance with toileting, bedpan use, and other personal care needs. Observations and interviews revealed that call lights were often left unanswered for extended periods, particularly on weekends and night shifts. For instance, Resident #16's call light was not answered for 7 minutes and then again for 9 minutes, causing the resident to wait for assistance with toileting. Similarly, Resident #57 reported waiting up to an hour for assistance with a bedpan, leading to episodes of incontinence due to the lack of timely help. Residents consistently expressed concerns about the long wait times for staff assistance, especially during the night and weekend shifts. Resident #62 mentioned having to wait up to an hour for bathroom assistance during meal times, while Resident #32 reported frequent accidents due to delayed responses to call lights. The Resident Council Meeting highlighted that 9 out of 10 residents experienced long wait times for call light responses, particularly on the night shift and weekends. Staff interviews corroborated these findings, with CNAs and nurses acknowledging the challenges posed by insufficient staffing levels, especially during weekends when call-outs and no-shows were common. The facility's staffing plan indicated a minimum staff-to-resident ratio that was not consistently met, leading to significant delays in providing necessary care. For example, on one observed day, only two CNAs were available for 30 residents, resulting in prolonged wait times for assistance. The lack of administrative staff presence on weekends further exacerbated the issue, as CNAs struggled to manage the workload. This deficiency in staffing directly impacted the residents' ability to attain and maintain their highest practicable physical, mental, and psycho-social well-being, as evidenced by the numerous instances of delayed care and unmet needs.
Failure to Ensure Nursing Competencies for IV Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to ensure the safety and well-being of a resident receiving intravenous (IV) antibiotics. Specifically, six nurses lacked the necessary competencies and certification to provide appropriate Central Venous Access Device (CVAD) care and services for a resident with a left hip infection. The facility's policy required documented education and competency in the management of vascular access devices, but this was not adhered to for the nurses involved in the resident's care. The resident, who had severe cognitive impairment and a recent hip replacement surgery, was admitted with diagnoses including Alzheimer's disease and a bacterial infection. Physician's orders included specific instructions for the care and maintenance of a Peripherally Inserted Central Catheter (PICC) line, which was used to administer IV antibiotics. Despite these orders, the facility did not ensure that the nurses providing care had the required competencies, as evidenced by the lack of documentation for their IV certification and competency. Interviews with the Administrator and Director of Nurses (DON) revealed that the facility had been without a Staff Development Coordinator (SDC) since February, and there was no system in place to verify the competencies of the nurses providing IV care. The Administrator acknowledged the oversight and the inability to provide evidence of the required training and competencies for the nurses involved. This deficiency was identified through observation, interviews, and a review of records and policies, highlighting a significant lapse in ensuring the safety and well-being of the resident receiving IV antibiotics.
Failure to Provide Privacy and Dignity During Personal Care
Penalty
Summary
The facility failed to ensure that Resident #25 was provided privacy and dignity during personal care. Specifically, the staff did not provide appropriate clothing or covering for the resident's private areas while being transported to and from the shower. The resident, who has diagnoses including cognitive communication deficit and mood disorder, was observed being assisted by a CNA while seated on a shower chair and dressed in a hospital gown. The resident's legs, bare bottom, and private parts were exposed as they were moved down the hallway to the shower room. This observation was confirmed by another CNA who noted that a blanket or towel should have been used to cover the resident's lower extremities to maintain privacy and dignity. Further observations revealed that when the resident was being transported back to their room, their bare bottom remained visible while seated on the shower chair. Multiple staff members were present in the hallway during this time, witnessing the resident's exposure. Interviews with the involved staff confirmed that the resident should have been covered to prevent exposure. The facility's policy on promoting and maintaining resident dignity was not followed, leading to this deficiency.
Failure to Notify Physician and Resident Representative of Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician and the resident representative of a change in skin condition for a resident who was found bleeding from the left index finger while on anticoagulant therapy. The facility's policy required immediate notification of the physician and resident representative in such cases, but this was not done. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed with an undated bandage on the left index finger on multiple occasions. The nurse's note indicated the bleeding was treated, but there was no documentation of physician or resident representative notification or new treatment orders. Interviews with the Unit Manager and Director of Nurses revealed that no investigation or incident report was completed for the bleeding incident, which should have been done according to facility policy. The Director of Nurses was unaware of the incident until informed by the surveyor and confirmed that the required notifications were not made. The nurse who documented the incident admitted that the physician and resident representative were not notified as required.
Inaccurate MDS Assessment for Pressure Injury
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was accurate for one resident out of a total sample of 17 residents. Specifically, the facility did not accurately code that a resident had a pressure injury. The resident, who was admitted in October 2020 with diagnoses including Dementia and Diabetes, developed a Stage 2 pressure injury in November 2022 that was not resolved until March 2024. However, the MDS assessment did not indicate the presence of this pressure injury. During an interview, the MDS Nurse confirmed that the assessment was coded incorrectly and required modification.
Failure to Monitor and Assess Skin Conditions and CVAD Catheter Site
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards relative to monitoring and assessing the skin condition for two residents. For one resident, the facility did not perform weekly skin assessments, notify and obtain orders from the physician when a new skin area of concern was identified, and failed to monitor a Central Venous Access Device (CVAD) access site relative to measuring and documenting the external catheter length according to standards of practice. Specifically, the resident was found with blood on their hands, and the source of the bleeding was not properly documented or treated according to protocol. Additionally, the resident's CVAD catheter site was not properly monitored, and there was no documented evidence of the external catheter length being measured upon re-admission or during subsequent assessments, as required by the facility's policy and physician's orders. The Director of Nursing (DON) and Unit Manager (UM) acknowledged these deficiencies during interviews with the surveyor, noting that incident reports, physician notifications, and treatment orders were not completed as required. For another resident, the facility failed to perform weekly skin assessments per facility policy and physician's order, and did not implement a Nurse Practitioner (NP) recommendation relative to edema. The resident had severe cognitive impairment and was usually understood by others. Despite having a physician's order for weekly skin assessments and a recommendation to keep their legs elevated to manage edema, there was no evidence that these assessments were completed or that the recommendation was integrated into the resident's care plan. Observations by the surveyor revealed that the resident's legs were reddened and edematous, and the resident reported not being aware of any treatments in place to alleviate their condition. Interviews with nursing staff and the UM confirmed that the required skin assessments and care plan updates were not performed. The facility's policies for CVAD catheter dressing changes and skin assessments were not followed, leading to inadequate monitoring and care for the residents. The deficiencies were identified through a combination of record reviews, observations, and staff interviews, highlighting a failure to adhere to professional standards and facility protocols. The DON and UM acknowledged the lapses in care and documentation, indicating a need for improved compliance with established procedures to ensure resident safety and well-being.
Failure to Investigate and Implement Interventions for Skin Issues
Penalty
Summary
The facility failed to investigate and implement interventions for accident/hazard incidents for two residents. For Resident #60, who had severe cognitive impairment and required assistance with activities of daily living, the facility did not thoroughly investigate or add interventions when a new skin area was identified on the resident's left index finger. Despite the resident being found with blood on their hands and a subsequent bandage being observed on multiple occasions, no incident report was completed, and the physician and resident representative were not notified. The Director of Nurses was unaware of the issue until it was brought to her attention by the surveyor. For Resident #57, who was cognitively intact and at risk for pressure injuries, the facility did not thoroughly investigate or add interventions when a new pressure injury was identified on the resident's right sacrum. The injury was reported to have occurred after the resident was on a bedpan for longer than usual. Despite the wound being documented and treated, no changes were made to the resident's plan of care, and no incident report or investigation was completed. The Unit Manager and Director of Nurses acknowledged that an investigation should have been initiated but was not. The facility's policy on wound and skin care required a full body skin assessment and documentation upon the identification of any new pressure injury. However, this policy was not followed for either resident, leading to a lack of proper investigation, notification, and intervention for the identified skin issues.
Failure to Perform Trauma Assessment and Develop Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to perform a trauma assessment on admission and develop a trauma care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted in February 2023, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the resident's PTSD diagnosis, the medical record did not indicate that a trauma assessment was ever completed, nor was there a care plan developed to address the resident's PTSD and potential triggers for re-traumatization. During an interview, the social worker confirmed that the facility did not utilize a trauma assessment and that information about a resident's trauma history usually emerged during the initial social service assessment or a visit with the psychiatric nurse practitioner. The social worker acknowledged that a care plan should have been developed to identify the resident's triggers for re-traumatization. However, upon review, it was found that no trauma assessment was completed, and no PTSD care plan was in place for the resident, as required by the facility's policy on trauma-informed care.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to ensure an accurate accounting of a controlled medication, specifically Lorazepam (Ativan), in the controlled substance accountability record book. During an observation, the surveyor noted that one of the controlled substances lock boxes in the medication storage room was unlocked. Nurse #5 found an opened 20cc Lorazepam syringe with 15cc remaining, labeled for a resident who had expired in February 2024. This medication was not part of the controlled substance count and was not recorded in the corresponding controlled substance accountability record book, as required by the facility's policy and federal and state regulations. Nurse #5 confirmed that the Lorazepam should have been counted and recorded in the controlled substance accountability log book for the St. Luke's Unit front medication cart. The Director of Nurses (DON) stated that all controlled substances, including those in the medication room refrigerator, should be counted, recorded, and reconciled by two nurses at the beginning and end of each shift. The failure to account for the Lorazepam indicates a lapse in adherence to the facility's policy on the handling, storage, and record-keeping of controlled substances.
Failure to Monitor for Side Effects and Adverse Reactions to Anticoagulant Medication
Penalty
Summary
The facility failed to monitor for side effects and adverse reactions to medications for one resident out of a total sample of 17 residents. Specifically, the facility staff did not monitor for side effects and adverse reactions related to the use of an anticoagulant medication for a resident who was admitted with diagnoses of Pulmonary Embolism and Atrial Fibrillation. The resident had an order to monitor for specific symptoms such as discolored urine, black tarry stools, sudden severe headache, numbness and tingling, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. The monitoring was to be documented on the Medication Administration Records (MARs) with a 'Y' if no symptoms were observed and an 'N' if any symptoms were observed, along with a progress note if necessary. However, the review of the resident's clinical record and MARs for March and April 2024 indicated no documented evidence that any monitoring for side effects and/or adverse reactions from anticoagulant therapy was being done as required. During an interview, a nurse confirmed that residents prescribed anticoagulant medications should be monitored for signs and symptoms such as nose bleeds, bruising, and tarry stools, and that this monitoring should be documented on the MAR. The nurse reviewed the resident's medical record and confirmed that the required monitoring was not documented. The nurse acknowledged that residents receiving anticoagulants should be monitored per shift and that it should be documented whether they were monitored with no symptoms or with symptoms. The lack of documentation indicated that the resident was not being monitored for signs and symptoms of anticoagulant medication use as required.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Valium, was limited to 14 days and reviewed by the Physician for continued use for one resident. The resident, who was admitted with Alzheimer's disease, had a PRN order for Valium 5 mg to be given every 8 hours as needed for spasms. The medication was administered 9 times in March and 5 times in early April. However, there was no documented evidence that the PRN Valium had been assessed by the Physician and a duration given for its use beyond 14 days. During an interview, the Unit Manager confirmed that PRN Valium should be ordered for 14 days and then reassessed by the Physician or Practitioner. The Unit Manager stated that upon assessment, the Physician can continue the medication for PRN use and indicate a duration for re-evaluation, schedule the PRN medication, or discontinue it. This failure to reassess and document the continued use of PRN Valium beyond 14 days led to the deficiency noted in the report.
Failure to Implement and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) were properly implemented and adhered to by staff for two residents, leading to potential infection control issues. Resident #118, who was admitted with a left hip fracture and had an open wound, was observed being assisted by a CNA into the bathroom without the CNA wearing a gown, despite the requirement for gown and gloves during high-contact care activities. The CNA admitted to only wearing gloves during toileting assistance, contrary to the facility's EBP policy. Resident #60, admitted with a bacterial infection and a vascular access site, was also not properly managed under EBP. The resident required assistance with various personal care activities and had a PICC line for IV antibiotics. Observations revealed that CNAs and a nurse did not consistently wear gowns while providing care, including during the administration of IV antibiotics and transferring the resident using a hoyer lift. The staff members either wore only gloves or a surgical mask, failing to comply with the EBP requirements. Interviews with the staff, including CNAs and a nurse, indicated a lack of awareness or understanding of the EBP requirements. One CNA was unaware of the precautions for Resident #60, and another admitted to not wearing a gown during a high-contact activity. The Unit Manager confirmed that staff should don gowns and gloves for direct care under EBP, highlighting a gap in adherence to infection control protocols for residents with specific medical conditions requiring enhanced precautions.
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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