Nevins Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Methuen, Massachusetts.
- Location
- Ten Ingalls Court, Methuen, Massachusetts 01844
- CMS Provider Number
- 225409
- Inspections on file
- 25
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Nevins Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and muscle weakness was left without assistance to eat, both in their room and the dining room, leading to a lack of dignified dining experience. Additionally, CNAs on two units were observed using phones while feeding residents, which is against facility policy.
The facility failed to secure medication and treatment carts on three of four units, leaving them unlocked and unsupervised. Despite the facility's policy requiring all drugs and biologicals to be stored securely, surveyors observed multiple instances of unsecured carts on the B Unit, TCU, and A Unit. Nurses acknowledged the carts should have been locked, indicating a lapse in adherence to storage protocols.
The facility failed to comply with professional standards for food storage and labeling, as observed during a survey. Unlabeled and improperly stored food items were found in the kitchen and shared kitchenette refrigerators, including a staff water bottle stored with resident food. The Food Service Director acknowledged the issues and confirmed the facility's policy of labeling and discarding food after three days, but was unsure about the origin of some undated items.
A facility failed to notify the physician or NP of abnormal lab results for a resident with serious health conditions. The resident's TSH and BMP lab results were not communicated to the regular NP or primary doctor, despite instructions to do so. The DON acknowledged that abnormal labs should be reported to the primary medical personnel, which was not done.
The facility failed to develop and implement comprehensive care plans for residents, including one with a history of suicidal ideation, another requiring an air mattress for pressure ulcer prevention, and a third needing assistance with feeding. Staff were unaware of these needs, and observations confirmed the lack of appropriate interventions.
A resident with dementia and muscle weakness required increased assistance with feeding, but the care plan was not updated to reflect this change. Observations showed the resident was unable to reach or consume meals independently, and interviews confirmed the resident's total dependence on staff for feeding. The DON indicated it was the Nurse Unit Manager's responsibility to update the care plan, which was not done.
The facility failed to implement a physician's order for air booties for a resident at risk of pressure ulcers and did not obtain a timely treatment order for another resident's draining wound. Despite care plans indicating the need for air booties, observations showed inconsistent application. Additionally, a resident with a draining wound did not have a treatment order until days after the issue was identified.
A resident with dementia and muscle weakness, requiring substantial assistance with eating and bed mobility, was left without necessary help during meals. Observations showed meals placed out of reach and no staff assistance provided, despite the resident's total dependence on staff for care. Interviews confirmed the expectation for staff to provide care, which was not met.
The facility failed to follow physician orders for pressure ulcer care for two residents. One resident's heels were not elevated as ordered, and another resident's wound care recommendations, including the use of Vashe and dressing changes, were not implemented. Despite available supplies and staff expectations, these deficiencies were confirmed through observations and interviews.
A resident with dementia and a history of falls was not adequately supervised during a period of agitation, leading to an unwitnessed fall. Despite having a care plan that required supervision and a chair alarm, staff failed to monitor the resident, resulting in a hospital visit for a possible pelvic fracture.
A resident with dementia and chronic pain experienced significant weight loss due to the facility's failure to provide fortified foods as ordered. Despite having a care plan that included fortified foods and calorie condiments, the resident was not consistently served these items. Staff interviews revealed a lack of communication regarding the resident's preferences, contributing to the deficiency.
A facility failed to follow professional standards for PICC line care by not obtaining weekly measurements of a resident's PICC line, as required by physician orders. The resident, with multiple health conditions, had a PICC line for IV medications. Observations and record reviews showed a lack of documentation for these measurements, and staff confirmed the oversight.
A facility failed to include a stop date for a PRN antipsychotic medication for a resident with dementia, contrary to its policy requiring time-limited PRN orders. The resident, moderately cognitively impaired and needing assistance with daily activities, was prescribed Quetiapine Fumarate without a specified stop date. The DON acknowledged that PRN antipsychotics should be limited to 14 days.
The facility failed to accurately document physician orders and medication administration for three residents. A resident's heels were not elevated as ordered, another resident's acetaminophen administration was not recorded, and a third resident's air mattress functionality was inaccurately documented despite the absence of an air mattress. These discrepancies were confirmed through observations and staff interviews.
A resident at high risk for falls, with severe cognitive impairment, was left unsupervised on a commode without an alarm, contrary to their care plan. This led to a fall and a fractured hip requiring surgery. Staff interviews and observations confirmed the resident was known to be impulsive and had a history of falls, yet was left alone without necessary monitoring.
A resident at high risk for falls, known to be impulsive, was left unattended on a commode by a nurse who disabled the resident's alarm. The resident fell, resulting in a right hip fracture requiring surgery. Staff interviews confirmed the resident's care plan required supervision and alarms, which were not adhered to, leading to the incident.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #140, who has dementia and muscle weakness, and requires substantial assistance with eating. On multiple occasions, Resident #140 was left in a position where they could not access their food independently. On one occasion, the resident was observed trying unsuccessfully to reach their breakfast while lying in bed, and on another, they were left asleep in the dining room without being served while others ate. Staff did not assist the resident in a timely manner, leaving them without the necessary support to eat. Additionally, on Units A and C, CNAs were observed using their phones while feeding residents, which is against the facility's policy. One CNA was seen scrolling through their phone while feeding a resident, and another had a wireless headphone emitting sound while entering multiple resident rooms. The Director of Nursing confirmed that staff should not be on their phones or have headphones on while providing care, as it detracts from the residents' dignity and the quality of care provided.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with accepted professional standards of practice. Specifically, the nursing staff did not secure medication and treatment carts on three of the four units. The facility's policy, dated November 2020, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with compartments locked when not in use. However, observations revealed that treatment and medication carts were left unlocked and unsupervised on multiple occasions across different units. On December 10th and 11th, 2024, surveyors observed several instances where treatment and medication carts were left unlocked and unattended. On the B Unit, a treatment cart was found unlocked and unsupervised, and Nurse #3 acknowledged that it should have been locked. Similar observations were made on the Transitional Care Unit (TCU) and the A Unit, where treatment and medication carts were left unsecured. During an interview, Nurse #2 confirmed that carts should never be left unlocked unless a nurse is present, indicating a lapse in adherence to the facility's storage policy.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a survey. The surveyor noted several instances of improperly stored and unlabeled food items in the facility's kitchen and shared kitchenette refrigerators. Specifically, a water bottle with an employee's initials was stored next to resident food in the walk-in refrigerator, and multiple food items, including cooked chicken, liquid eggs, whipped cream, cheddar cheese, and mozzarella cheese, were found without proper labeling or dates. Additionally, in the second-floor shared kitchenette refrigerator, several containers of resident food were undated, and a sign indicated that food should be labeled with the resident's name, date, and room number, and discarded after three days if not labeled. During an interview, the Food Service Director (FSD) acknowledged that the water bottle should not have been stored with resident food and confirmed that all food should be labeled and dated when opened or prepared, with a discard policy of three days. The FSD also stated that kitchen staff are responsible for checking the kitchenette every morning to discard any undated, unlabeled, or expired items. However, the FSD was unsure about the origin of the undated liquid eggs, indicating a lapse in the facility's food safety procedures.
Failure to Notify Medical Personnel of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of lab results for a resident with significant medical conditions, including stage four kidney disease, heart failure, and diabetes. The resident had a physician's order for a TSH lab to be drawn, and the results were received on December 6, 2024. Nurse #8 informed a covering nurse practitioner of the abnormal result, who advised maintaining the current medication dosage and following up with the regular nurse practitioner on the following Monday. However, the regular nurse practitioner was not informed of the abnormal TSH lab result, and the lab report did not have her initials, indicating she had not reviewed it. The Director of Nursing acknowledged that the nursing staff should have followed up with the resident's regular medical provider as instructed. Additionally, the facility did not notify the resident's regular nurse practitioner or primary doctor of abnormal BMP lab results drawn on November 11, 2024. The progress notes for November and December 2024 did not document any notification of these abnormal lab values to the appropriate medical personnel. The regular nurse practitioner confirmed during an interview that she was unaware of the abnormal BMP lab results. The Director of Nursing stated that all abnormal labs should be reported to the primary physician or nurse practitioner, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of suicidal ideation (SI). Despite the resident being cognitively intact and having documented history of SI, suicide attempts, and self-injurious behaviors, there was no care plan addressing these issues. Interviews with staff, including a CNA, Nurse Unit Manager, and Social Worker, revealed that they were unaware of the resident's history of SI, indicating a lack of communication and documentation regarding the resident's mental health needs. Another deficiency involved the failure to implement a physician's order for an air mattress for a resident with severe cognitive impairment and high risk for skin breakdown. Despite having an open wound and a care plan indicating the need for an air mattress, observations confirmed that the resident's bed did not have the required air mattress. Interviews with a nurse and the Director of Nursing confirmed the expectation that the resident should have had an air mattress as per the care plan and physician's order. The facility also failed to develop a care plan for a resident requiring assistance with feeding. The resident, who had severe cognitive impairment and required supervision or assistance for eating, was observed with untouched meal trays and no staff present to assist. Documentation indicated the resident needed assistance with eating for a significant number of meals, yet no care plan was in place to address this need. Interviews with a CNA and the MDS Nurse confirmed the necessity of a care plan for residents requiring feeding assistance.
Failure to Update Care Plan for Resident's Increased Feeding Assistance Needs
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after a quarterly review assessment. Specifically, the care plan for a resident with dementia and muscle weakness was not updated to reflect the increased level of assistance needed for feeding. The resident was admitted in August 2024 and had a severely impaired cognition score on the most recent Minimum Data Set (MDS) assessment. The MDS indicated that the resident required substantial to maximal assistance with eating, and the Licensed Nursing Summary noted the resident was dependent for eating. Observations revealed that the resident was unable to reach or consume meals independently. On two separate occasions, the resident was left without assistance to eat, despite being unable to reach the food. Interviews with the CNA and Nurse Unit Manager confirmed that the resident was totally dependent on staff for feeding. The Director of Nursing stated that it was the responsibility of the Nurse Unit Manager to update the care plan and Kardex to reflect the resident's current needs, which had not been done.
Failure to Implement Physician Orders and Obtain Timely Wound Treatment
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. For Resident #32, the facility did not implement a physician's order to apply air booties while the resident was in bed. Despite the resident's risk for developing pressure ulcers and having an unhealed unstageable wound, observations on multiple occasions revealed that the resident was either without air booties or had them applied incorrectly. The resident's care plan and CNA Kardex indicated the need for air booties, yet this was not consistently followed, as confirmed by Nurse #4 during an interview. For Resident #74, the facility did not obtain a physician's order for wound treatment in a timely manner. The resident, who was severely cognitively impaired, developed blood blisters on the right lower leg, which were noted to have purulent drainage. Although antibiotics were ordered by a Nurse Practitioner, there was no treatment order for the draining wound until several days later. The Nurse Practitioner and the Director of Nursing both expressed expectations that a treatment should have been in place for the draining wounds, indicating a lapse in the facility's adherence to professional standards of care.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident diagnosed with dementia and muscle weakness, who was admitted in August 2024. The resident, who scored a 2 out of 15 on the Brief Interview for Mental Status exam indicating severely impaired cognition, required substantial/maximal assistance with eating and was dependent on staff for bed mobility and feeding. Despite these needs, the facility did not provide the required assistance, as observed during multiple surveyor visits. On several occasions, the resident was left in bed with meals placed out of reach, without any staff assistance to help with feeding or repositioning. Observations showed that the resident was unable to pull themselves up or reach the food, and no staff were present to assist. Interviews with the CNA and Unit Manager confirmed that the resident was totally dependent on staff for care, and it was expected that staff provide such care. However, the necessary assistance was not provided, leading to the deficiency noted in the report.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to physician orders for the prevention and care of pressure ulcers for two residents. Resident #94, who was admitted with diagnoses including cerebral vascular accident and hemiplegia, was observed multiple times lying in bed without his/her heels elevated, contrary to the physician's order to elevate heels while in bed every shift. Despite being at high risk for skin breakdown, the care plan did not include this specific intervention, and observations confirmed the lack of compliance with the physician's directive. Resident #26, admitted with dementia and severe cognitive impairment, had a stage II pressure ulcer on the coccyx. The wound physician recommended specific wound care treatments, including the use of Vashe and dressing changes twice daily. However, the medical record showed that these recommendations were not reviewed or implemented. Interviews with nursing staff and management revealed an expectation that the wound physician's recommendations should be implemented promptly, yet this was not done, and the wound did not improve over time. The failure to follow physician orders for both residents was confirmed through observations, record reviews, and staff interviews. The facility had the necessary supplies, such as Vashe, available, and there were no reported shortages. Despite this, the orders were not executed, and the residents' care plans were not updated to reflect the necessary interventions, leading to a deficiency in the care provided.
Failure to Supervise Agitated Resident Leads to Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident who was displaying symptoms of agitation and walking independently. The resident, who was moderately cognitively impaired and required assistance with all activities of daily living, was admitted with diagnoses including dementia. The care plan for the resident included interventions for managing agitation and ensuring supervision during ambulation, but these were not effectively implemented. On the day of the incident, the resident was agitated due to a fire alarm and was observed walking independently, which was against the care plan that required supervision and assistance. Despite the presence of a chair alarm, staff did not adequately monitor or assist the resident, leading to an unwitnessed fall. The fall resulted in the resident being sent to the hospital for evaluation, where a possible pelvic fracture was identified. Interviews with staff revealed that the resident had a history of falls and was known to become easily agitated. Staff were aware of the need to respond to the chair alarm and supervise the resident, but failed to do so during the incident. The Director of Nursing confirmed that care plans should be followed, indicating a lapse in adherence to the established protocols for fall prevention and resident supervision.
Failure to Provide Fortified Foods to Resident
Penalty
Summary
The facility failed to provide fortified foods for a resident, identified as Resident #23, who was at risk for malnutrition. Resident #23, admitted with diagnoses including dementia and chronic pain, was observed to have a significant weight loss of 6.10% over a short period. Despite having orders for fortified foods and calorie condiments, the resident was not consistently served these items. Observations revealed that the resident's meals often lacked the fortified foods as ordered, and the resident's meal ticket indicated the need for fortified foods with all meals. Interviews with staff, including a CNA and the Food Service Director, confirmed that Resident #23 was not receiving the fortified foods as required. The CNA noted that the resident was not a good eater, and the Food Service Director acknowledged that fortified foods were not being served as ordered. The Dietitian was unaware that the resident did not like the fortified foods and had not been informed by the nursing staff. The facility's records did not document the resident's refusal or dislike of fortified foods, indicating a communication breakdown between staff and the dietitian, leading to the deficiency.
Failure to Monitor PICC Line Measurements
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident. Specifically, the facility did not obtain weekly measurements of the external length of the PICC line for a resident who was readmitted with conditions including osteomyelitis, bacteremia, lymphedema, and type 2 diabetes. The resident's physician order required weekly measurements of the PICC line's external length to ensure it had not migrated, which is crucial for safe and effective treatment. During an observation, it was noted that the PICC line dressing was dated several days prior, and a review of nursing progress notes and assessments revealed a lack of documentation indicating that the required measurements were taken. Interviews with nursing staff confirmed that the measurements should have been obtained and documented weekly with the dressing change, as per the physician's order. This oversight represents a failure to follow established protocols for PICC line management, potentially impacting the resident's treatment.
Failure to Include Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically by not including a stop date for a PRN antipsychotic medication. The facility's Psychotropic Medication Policy and Procedure requires that PRN orders for psychotropic medications be time-limited and used only for specific, clearly documented circumstances. However, for a resident with dementia and cognitive communication deficiency, the facility issued a PRN order for Quetiapine Fumarate without a specified stop date, which is contrary to the policy. The resident, who was moderately cognitively impaired and required assistance with all activities of daily living, was prescribed Quetiapine Fumarate 25 mg to be administered every 12 hours as needed for agitation and restlessness. The medication administration record showed that the resident received two doses and refused the medication twice in November. During an interview, the Director of Nursing acknowledged that PRN antipsychotic medications should be limited to 14 days, indicating a failure to adhere to the facility's policy and federal regulations.
Documentation Failures in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to accurately document the completion of physician orders in the clinical records for three residents. For Resident #94, who was at high risk for skin breakdown due to cerebral vascular accident and hemiplegia, the facility did not correctly document that the resident's heels were elevated while in bed, as per the physician's order. Observations on multiple occasions revealed that the resident's heels were not elevated, despite staff having initialed the Treatment Administration Record (TAR) indicating compliance with the order. Resident #124, who suffers from chronic pain syndrome and osteoarthritis, experienced a failure in documentation regarding the administration of acetaminophen. Although the resident expressed pain and was observed receiving acetaminophen from a nurse, the Medication Administration Record (MAR) did not reflect that the medication was administered on the specified date. This discrepancy was confirmed during an interview with the Unit Manager, who acknowledged the lack of documentation. For Resident #52, diagnosed with Alzheimer's Disease and at high risk for skin breakdown, the facility inaccurately documented the functionality check of an air mattress that was not present. Despite the physician's order to check the air mattress every shift, observations confirmed the absence of an air mattress, and the MAR/TAR indicated that checks were performed. This was corroborated by a nurse and the Director of Nursing, who confirmed the documentation inaccuracies.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions identified in a resident's care plan, which led to a fall and injury. The resident, who was assessed as being at high risk for falls and severely cognitively impaired, required the use of bed and chair alarms to alert staff when attempting to stand or transfer alone. On the day of the incident, the resident's bed alarm sounded when they transferred themselves from bed to the bedside commode. Nurse #1 responded to the alarm, turned it off, and left the resident alone on the commode without an alarm in place. Subsequently, the resident fell and was later diagnosed with a fractured right hip, requiring surgical intervention. Interviews with staff revealed that the resident was known to be impulsive and had a history of falls. Despite this knowledge, the resident was left unsupervised on the commode, contrary to the care plan's requirements for continuous monitoring and alarm use. Observations during the survey confirmed that the resident was left alone without an alarm on multiple occasions. The Director of Nurses acknowledged that residents requiring bed and chair alarms should not be left unattended while on the toilet or commode. The failure to adhere to the care plan's interventions directly contributed to the resident's fall and subsequent injury.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident assessed as high risk for falls, who was known to be impulsive and had interventions in place, including bed and chair alarms, to alert staff when attempting to stand or transfer independently. On the specified date, after the resident's bed alarm sounded, Nurse #1 responded and found the resident had self-transferred to a bedside commode. Nurse #1 disabled the alarm, left the resident unattended with a call bell, and exited the room. Shortly after, the resident fell, resulting in a right hip fracture that required surgical intervention. Interviews with staff, including Nurse #1, Unit Manager #1, and the Director of Nurses (DON), confirmed that the resident was known to be impulsive and had a history of falls. The DON stated that residents requiring bed and chair alarms should not be left unattended on a commode. The incident occurred because Nurse #1 left the resident unsupervised without an alarm, contrary to the resident's care plan and facility policies, leading to the resident's fall and subsequent injury.
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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