Neville Center At Fresh Pond For Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cambridge, Massachusetts.
- Location
- 640 Concord Avenue, Cambridge, Massachusetts 02138
- CMS Provider Number
- 225378
- Inspections on file
- 19
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Neville Center At Fresh Pond For Nursing & Rehab during CMS and state inspections, most recent first.
Two residents with a history or presence of heel pressure ulcers did not receive physician-ordered heel offloading devices while in bed, despite documentation indicating otherwise. Staff were unaware of the residents' needs and misunderstood the orders, resulting in the residents being observed without booties and with heels directly on the mattress. No refusals or clinical justifications were documented for not following the prescribed interventions.
Two residents experienced deficiencies in nutrition and hydration management when staff failed to follow protocols for significant weight loss and fluid restriction. One resident with chronic kidney disease and dysphagia had a notable weight loss without required re-weighing or notification of the RD or MD, while another with heart failure received fluids above the prescribed limit without physician notification or documentation of non-compliance.
A resident with a PICC line did not receive dressing changes as ordered by the physician, with the dressing remaining unchanged for 19 days and part of it lifting, exposing the catheter. Nursing staff documented the dressing changes as completed in the TAR when they had not been performed, and there was no documentation explaining the missed care. The facility's policy for weekly sterile dressing changes was not followed.
Surveyors found that opened insulin and IV emergency kits on two units were not properly documented or reordered from the pharmacy after use. Staff were unable to confirm when the kits were accessed or if replacements had been requested, in violation of facility policy requiring immediate reordering and documentation.
Nursing staff did not date multiple opened bottles of eye drops on a medication cart, contrary to facility policy and manufacturer guidelines. Both nursing and administrative staff confirmed that opened medications should be dated, but this was not done for several medications observed during the survey.
Two residents with orders for PICC dressing changes, heel booties, and padded side rails did not receive these interventions as ordered, yet nursing staff documented them as completed in the medical record. Observations and interviews confirmed that the interventions were not implemented, and there was no documentation of refusal or rationale for non-compliance.
A resident with an activated Health Care Proxy and signed consent for the COVID-19 vaccine did not receive the vaccine upon admission. The Unit Manager was waiting for a vaccination clinic, unaware of the facility's policy allowing immediate administration. The resident later tested positive for COVID-19, highlighting a failure in the facility's vaccination process.
The facility failed to provide a dignified dining experience for residents on the 3rd floor unit, as observed by surveyors who noted that meals were served on institutional trays during breakfast and lunch. This was confirmed by a unit manager, indicating a violation of residents' rights to a dignified existence.
A resident with multiple fall risk factors, including Parkinson's disease and orthostatic hypotension, was admitted without a baseline care plan to address their fall risk. Despite a fall risk assessment indicating moderate risk, the care plan was not created until weeks after admission, following a fall incident. The discrepancy in the care plan's creation and initiation dates was noted, with staff unable to explain the delay.
A resident admitted with malnutrition, kidney disease, and depression was found to have only two carious teeth and expressed a need for dental care, which was not addressed in their care plan. Despite being cognitively intact and having mild dysphagia due to poor dentition, the facility failed to include a dental care plan. Staff interviews confirmed the oversight and discrepancies in the admission assessment.
A resident with epilepsy was found with unpadded side rails, contrary to physician orders, after being moved to a new room. Staff were unaware of the need for padded rails, indicating a communication lapse. The DON acknowledged the oversight.
A surveyor observed a lapse in medication security on the second floor unit when an expired bottle of liquid Trazodone was left unsecured on the nursing station desk. The medication was unattended for almost 10 minutes, despite being near a common area hallway where a resident was passing by. Unit Manager acknowledged the oversight but left the medication unsecured again, indicating a failure to adhere to the facility's policy on securing medications.
The facility failed to provide timely dental care for two residents, resulting in deficiencies in oral health management. One resident with broken teeth and lost dentures did not receive a dental consultation, impacting their ability to chew and swallow. Another resident required new dentures, but the facility did not follow up on the dentist's recommendation for fabrication, despite initial consultations and communication with the resident's financial power of attorney.
The facility failed to maintain accurate medical records for two residents. One resident's dental status was inaccurately documented, leading to an incorrect MDS. Another resident's side rails were not padded as required after a room change, despite physician orders and care plans. Staff were unaware of the need for padded side rails, and the Treatment Administration Record inaccurately indicated they were padded.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide necessary treatment and interventions to promote healing and prevent new pressure ulcers for two residents. For one resident with a left heel pressure ulcer and severe cognitive deficits, physician orders required the use of bilateral booties and offloading of the left heel while in bed. Despite these orders, the resident was repeatedly observed in bed with heels directly on the mattress and without booties, and there was no documentation of refusal or rationale for not implementing the interventions. Staff interviews revealed a lack of awareness regarding the resident's wound and misunderstanding of the physician's orders, with some staff believing the interventions were only required during the night shift. Another resident, who had a history of a heel pressure ulcer and was dependent on staff for footwear, also had a physician order for wearing Prevelon boots while in bed. This resident was observed multiple times in bed without booties and with heels on the mattress, and no booties were visible in the room. The resident reported not being offered booties for a long time and expressed willingness to wear them if provided. Staff interviews indicated a lack of awareness and incorrect assumptions about when the interventions were required, with documentation inaccurately reflecting that the interventions were implemented every shift. In both cases, the facility's documentation on the Treatment Administration Record indicated that the prescribed interventions were carried out, but direct observation and staff interviews contradicted this. There was no evidence of resident refusal or clinical justification for not following the physician's orders, and staff were not consistently aware of the residents' needs or the specifics of the orders. The facility's failure to implement and accurately document the required interventions led to the deficiency.
Failure to Maintain Nutrition and Hydration Status for Two Residents
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of two residents by not following established protocols for monitoring and responding to significant changes in weight and fluid intake. For one resident with chronic kidney disease and dysphagia, there was a significant weight loss of over 10% between two recorded weights. Despite facility policy requiring re-weighing and notification of the Registered Dietician (RD) and physician for such discrepancies, the medical record did not show that these steps were taken. The RD acknowledged that the weight discrepancy may have been overlooked due to the resident moving floors, but confirmed that follow-up was still required. For another resident with heart failure and chronic respiratory failure, the facility did not adhere to a physician's order for a 1000 ml fluid restriction per 24 hours. Documentation showed that the resident consistently received more fluids than ordered, with daily intakes ranging from 1,100 to 1,200 ml. Facility policy required that any non-compliance with fluid restrictions or changes in the resident's condition be recorded and reported to the physician, but there was no evidence in the medical record that the physician was notified of the excess fluid intake. Interviews with staff confirmed that the established protocols for monitoring and reporting significant weight changes and fluid restriction compliance were not followed. The failures included not validating significant weight loss with a re-weigh and not notifying the appropriate clinical staff, as well as not documenting or reporting fluid intake above the prescribed limit to the physician.
Failure to Perform Timely PICC Dressing Changes per Physician Order
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) in accordance with professional standards and physician orders for one resident. The resident, who was admitted with diagnoses including sepsis and urinary tract infection and was cognitively intact, had a physician's order for weekly routine PICC dressing changes and as-needed changes. Despite this, the PICC dressing was observed to be 19 days old, with part of the dressing lifting and exposing the catheter to air. The resident reported that the dressing had only been changed twice since readmission, and there was no documentation in the nursing progress notes explaining why the dressing was not changed as ordered. Review of the Treatment Administration Record (TAR) showed that nurses documented the dressing change as completed on two occasions when it had not been done. Interviews with nursing staff confirmed that the dressing had not been changed according to the schedule, and staff were unable to provide a rationale for the missed care. The facility's policy required weekly sterile dressing changes using aseptic technique, but this was not followed for the resident in question.
Failure to Replace and Document Use of Emergency Medication Kits
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident by not properly managing emergency medication kits on two out of three units. During inspection, an opened insulin kit was found in the second-floor medication room refrigerator with some contents missing. There was no documentation indicating what had been removed, when it was removed, or who had removed the items. Additionally, there was no evidence that the kit had been reordered from the pharmacy for replacement. Staff interviewed were unable to confirm when the kit was accessed or if it had been reordered, despite facility policy requiring immediate reordering upon opening. A similar issue was observed on the third floor, where an intravenous (IV) emergency kit was found opened with some contents removed. Again, there was no documentation regarding the removal of items, and staff were unaware of when the kit was accessed or if it had been reordered. The facility's policy states that emergency kits should be exchanged or replenished by the pharmacy as needed, and staff interviews confirmed that kits should be reordered immediately after being opened. However, these procedures were not followed, resulting in a failure to meet the pharmaceutical needs of residents.
Failure to Date and Store Opened Medications per Policy
Penalty
Summary
Surveyors observed that nursing staff failed to ensure medications were dated upon opening and stored according to manufacturer’s guidelines, as required by facility policy and professional standards. During an inspection of a medication cart, two bottles of Lumigan eye drops, one bottle of pilocarpine eye drops, one bottle of latanoprost eye drops, and one bottle of timolol eye drops were found opened and undated. Interviews with a nurse and the Regional Director of Clinical Education and Administration confirmed that nurses are responsible for dating eye drops when opened and that this procedure was not followed in these instances.
Inaccurate Documentation and Failure to Implement Physician Orders for Pressure Injury and Safety Interventions
Penalty
Summary
The facility failed to accurately document and implement physician orders for two residents, resulting in multiple instances of inaccurate medical recordkeeping. For one resident with a history of sepsis, urinary tract infection, and diabetes, nurses documented that a peripherally inserted central catheter (PICC) dressing change was completed on two occasions when it had not been performed. Observations revealed that the PICC dressing had not been changed for 19 days, despite orders for weekly changes. The resident confirmed the dressing had only been changed twice since readmission, and staff interviews corroborated that documentation was inaccurate. Additionally, the same resident had physician orders for the use of heel booties while in bed and for padded side rails due to a seizure disorder. Despite these orders, the resident was repeatedly observed in bed without booties or offloaded heels, and the side rails were not padded. The resident stated that booties and side rail pads had not been offered or used for a long time, and staff confirmed that these interventions were not implemented as ordered. Nevertheless, nursing staff documented in the Treatment Administration Record (TAR) that these interventions were completed every shift, with no documentation of refusal or rationale for non-implementation. A second resident, with chronic kidney disease, diabetes, and severe cognitive deficits, also had physician orders for bilateral heel booties and offloading of heels while in bed. This resident was observed multiple times in bed without booties or offloaded heels, and the booties were not within reach. The resident reported not being offered the booties and experiencing discomfort from a heel wound. Staff interviews indicated a misunderstanding of the order's requirements, and the TAR reflected that the interventions were documented as completed every shift, despite not being implemented and without any record of refusal or explanation.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had an activated Health Care Proxy and had given signed consent for the vaccination upon admission. The resident, who was admitted in September 2024, had a medical history that included moderate dementia, cognitive communication deficit, and other health issues. Despite the signed consent form dated 09/03/24, the resident did not receive the vaccine and subsequently tested positive for COVID-19 on 11/06/24. The Unit Manager was aware of the signed consent but was waiting for a COVID-19 Vaccination Clinic to be scheduled at the facility to administer the vaccine. This was part of the Unit Manager's practice to hold onto consent forms until a clinic was scheduled. However, the Unit Manager was not familiar with the facility's COVID-19 Vaccination Policy and Procedures, which did not require waiting for a clinic to administer the vaccine. The Director of Nursing (DON) was informed on 11/18/24 that the resident had not received the vaccine despite the signed consent. The DON expected the Unit Manager to have obtained a physician's order, ordered the vaccine, and administered it without delay. The facility had the capability to obtain and administer the vaccine at any time, and there was no need to wait for a vaccination clinic. This oversight led to the resident not receiving the vaccine in a timely manner, increasing their risk of infection.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to provide residents with a dignified dining experience on the 3rd floor unit. Surveyors observed that during breakfast and lunch meals on two consecutive days, residents were served on institutional trays in the dining room. This practice was confirmed during an interview with Unit Manager #1, who stated that all meals are served on trays in the dining rooms. The observations and interview indicate a lack of attention to providing a dignified dining experience for the residents, which is a violation of their rights to a dignified existence and self-determination.
Failure to Develop Timely Fall Risk Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was at moderate risk for falls, as identified in their fall risk assessment. The resident, admitted in July 2024, had multiple diagnoses including difficulty in walking, ataxia, repeated falls, Parkinson's disease, syncope, and orthostatic hypotension. Despite these conditions, there was no baseline care plan or specific interventions documented to manage the resident's fall risk. The resident experienced a fall on July 8, 2024, but no injuries were reported. However, the absence of a care plan to address the fall risk was noted during a surveyor's review of the resident's records. The surveyor found that the falls care plan was created on July 23, 2024, although it was documented to have been initiated on the resident's admission date, July 7, 2024. The MDS Director and Unit Manager #3 were unable to explain the discrepancy in the care plan's creation and initiation dates. Unit Manager #3 stated that the fall risk assessment should have triggered the creation of a baseline falls care plan, but the goals section did not auto-populate, leading to a delay in the care plan's completion. This oversight resulted in the resident not having a comprehensive plan to address their fall risk upon admission.
Failure to Develop Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop a dental care plan for a resident who was admitted with diagnoses including malnutrition, kidney disease, and depression. The resident, who was cognitively intact, was observed to have only two carious top teeth and expressed a desire to see a dentist, mentioning that their partial plates were lost during the move to the facility. Despite these observations and the resident's expressed needs, the care plan initiated shortly after admission did not include any plan for addressing dental care. Further review of the resident's records revealed that the resident had missing or broken teeth and mild dysphagia due to lack of dentition, as noted in a nutrition/hydration assessment and speech therapy evaluations. The speech therapy notes indicated that the resident was not safe for a diet texture upgrade due to the absence of a lower denture, which was not found in the resident's mouth or room. Interviews with facility staff, including a unit manager and an MDS nurse, confirmed the absence of a dental care plan and highlighted discrepancies in the admission nursing assessment.
Failure to Pad Side Rails for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a seizure disorder by not padding the side rails of the resident's bed as ordered by the physician. The resident, who has a diagnosis of epilepsy and intact cognition, was observed on multiple occasions with unpadded side rails, despite physician orders and care plan interventions requiring padded side rails to prevent injury. The resident had recently been moved to a new room, and the side rail pads were not transferred to the new bed. Certified Nurses Assistants and a nurse confirmed that they were unaware of the requirement for padded side rails, indicating a lapse in communication and adherence to physician orders. The Director of Nurses and Assistant Director of Nurses acknowledged the oversight, attributing it to the room change and the failure to move the side rail pads. This deficiency highlights a failure in following established procedures to prevent accidents for residents at risk.
Medication Security Lapse on Second Floor Unit
Penalty
Summary
The facility failed to secure medication on the second floor unit, as observed by a surveyor. During the inspection, Nurse #1 was seen removing an expired bottle of liquid Trazodone from the refrigerator in the unit's locked medication room and handing it to Unit Manager #2. The Unit Manager then placed the medication on the nursing station desk, which was located near the common area hallway. This action left the medication unsecured and unattended, as there were no staff present at the desk or in the vicinity, and a resident was observed walking past the nursing station with a rehabilitation therapist. The surveyor noted that the Trazodone remained on the desk for almost 10 minutes without supervision. When Unit Manager #2 returned to the nursing station, she acknowledged that the medication should have been secured or attended to by nursing staff. Despite this acknowledgment, the Trazodone was again left unsecured and unattended when Unit Manager #2 left the nursing station. The surveyor observed this repeated oversight, highlighting the facility's failure to adhere to its policy of securing medications, which requires that drugs and biologicals be stored in locked compartments.
Failure to Provide Timely Dental Care for Residents
Penalty
Summary
The facility failed to provide timely dental care for two residents, leading to deficiencies in their oral health management. Resident #87, who was admitted with conditions including malnutrition, kidney disease, and depression, had broken and carious teeth and lost lower dentures. Despite a consent for dental services being signed in May 2024, the resident had not received a dental consultation by July 2024. Observations and interviews revealed that the resident expressed a desire to see a dentist, and the lack of dentures was impacting their ability to chew and swallow safely, as noted in speech therapy assessments. Resident #89, admitted with cancer, heart disease, and anxiety, required new dentures as recommended by a dentist in March 2024. Although the resident's care plan included coordinating dental care, and consent for services was obtained in April 2024, the facility did not follow up on the dentist's recommendation for denture fabrication. Interviews indicated that the facility had not pursued the status of the denture refabrication, despite the dentist's initial consultation and communication with the resident's financial power of attorney regarding costs.
Inaccurate Medical Records and Equipment Oversight
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care. For one resident, the nursing admission assessment inaccurately documented the dental status, stating there were no oral issues, despite observations and assessments indicating missing and carious teeth. This discrepancy was confirmed by the MDS nurse, who acknowledged that the admission nursing assessment was incorrect, resulting in an inaccurate MDS. For another resident, the facility failed to document the presence of side rail pads after a room change. Despite physician orders and care plans indicating the need for padded side rails due to a seizure disorder, observations revealed that the side rails were not padded. Certified Nurses Assistants were unaware of the requirement, and the Treatment Administration Record inaccurately indicated that the side rails were padded. Interviews with facility staff, including the Director of Nurses and Assistant Director of Nurses, confirmed that the resident's medical record was not accurately documented. The staff failed to ensure the transfer of necessary equipment, such as side rail pads, during the room change, leading to inaccurate documentation in the medical records.
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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