New England Homes For The Deaf, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Danvers, Massachusetts.
- Location
- 154 Water Street, Danvers, Massachusetts 01923
- CMS Provider Number
- 225768
- Inspections on file
- 15
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at New England Homes For The Deaf, Inc during CMS and state inspections, most recent first.
Surveyors observed improper food storage in facility refrigerators, including multiple unlabeled and undated food and beverage items, as well as expired products. Additionally, a staff member was seen handling residents' food and dinnerware with bare hands in the dining room, such as touching dinner rolls and straws directly. Both the DON and Foodservice Director confirmed these practices did not meet professional standards.
Staff did not maintain resident dignity during feeding, as a staff member was observed standing over a resident in a Broda chair and in bed while assisting with meals, contrary to facility policy and confirmed expectations by the unit manager and DON.
A resident with severe cognitive impairment was prescribed Seroquel, an antipsychotic, and the invoked Health Care Proxy was provided with an informed consent form that incorrectly listed the risks and benefits for an antidepressant rather than an antipsychotic. Nursing staff confirmed the error, resulting in the HCP not being fully informed about the medication's actual risks and benefits.
A resident with severe cognitive impairment and high fall risk was observed with foam wedges used as a fall intervention, but staff did not complete a restraint assessment for their use. Facility staff confirmed the absence of a restraint assessment and could not provide a restraint policy.
A resident with a cardiac pacemaker did not have a comprehensive, individualized care plan addressing their device, as required by facility policy. The medical record lacked essential pacemaker details such as the serial number, device type, paced rate, and cardiologist contact information. Staff interviews confirmed the omission of this information from the care plan and medical record.
Two residents did not receive care according to professional standards: one did not have a nurse practitioner's order for Zofran implemented after experiencing nausea and vomiting, and another had an air mattress in use without physician orders specifying the required settings, despite being at high risk for pressure ulcers. Nursing staff and management confirmed these omissions.
Two residents did not receive care in accordance with provider recommendations and professional standards: one did not receive a recommended oral antibiotic after IV therapy for osteomyelitis due to lack of communication between nursing staff and providers, and another did not have a urine specimen collected or provider notified after repeated failed attempts, resulting in transfer to the ER for acute cystitis.
A resident with multiple respiratory diagnoses was repeatedly observed receiving supplemental oxygen therapy without a physician's order, contrary to facility policy and professional standards. Nursing staff and leadership confirmed that an order is required, but none was found in the resident's records, care plan, or administration logs.
The facility failed to regularly inspect bed frames for potential entrapment risks, specifically in Zone 7, for all residents' beds. A resident with severe cognitive impairment was found with an inadequate bed bolster, creating a visible gap and entrapment risk. The facility's documentation of bed inspections was outdated, and staff confirmed that checks were only conducted annually.
A resident with multiple diagnoses, including deafness, blindness, and psychosis, had an incomplete MOLST form lacking the required provider's signature in section H, rendering the form invalid despite the resident's elected DNR status.
A facility failed to follow privacy and confidentiality policies when a Unit Manager used a personal cell phone to photograph a resident's wound. The incident was reported by a Social Worker and confirmed by multiple staff members, but no photo was found on the unit cell phone, raising concerns about the use of personal devices for clinical photography.
The facility failed to develop a care plan for a resident with PTSD and did not implement the falls care plan for another resident with severe cognitive impairment. The PTSD care plan was missing, and fall mats were not placed as required, leading to deficiencies in care.
The facility failed to ensure a resident's oxygen concentrator filter was free of significant dust. The resident, with asthma and congestive heart failure, had a care plan that did not reference their asthma or oxygen therapy. The Unit Manager and facility staff were unaware of the dusty filter, relying on a vendor for maintenance, and lacked a policy for filter maintenance.
A resident's wheelchair was found to be in disrepair, with missing and broken parts, despite the resident reporting the issue to staff months prior. Interviews revealed a lack of communication and responsibility among staff regarding the maintenance of the wheelchair.
Failure to Follow Food Storage and Handling Standards
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices as observed during a survey. In the kitchen, multiple food and beverage items were found in both the walk-in and reach-in refrigerators without labels or dates, including carafes of liquids, containers of juice, milk, soy milk, Lactaid milk, thickened juice, soda, chocolate whipped cream, and various prepared foods such as tuna salad, coleslaw, and baked beans. Some containers were labeled but had use-by dates that had already passed. The Foodservice Director confirmed that all opened food and drink containers should be labeled with their contents and date, and discarded after three days. In the second-floor dining room, a staff member was observed handling residents' food and dinnerware with bare hands. Specifically, the staff member touched dinner rolls with bare hands while spreading butter and opened straws by touching the area where residents would place their mouths. Both the Director of Nursing and the Foodservice Director stated that staff should not directly touch residents' food or dinnerware with bare hands. These actions were directly observed by the surveyor and confirmed as not in accordance with professional standards of food service safety.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
Staff failed to treat a resident with dignity during mealtimes by not sitting at eye level while assisting with feeding. Observations showed a staff member standing over a resident in a Broda chair during lunch and again standing over the same resident while feeding them in bed at breakfast. The facility's policy requires residents to be treated with dignity and respect at all times. Both the unit manager and the Director of Nursing confirmed in interviews that staff should not be standing over residents when providing feeding assistance.
Failure to Provide Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Health Care Proxy (HCP) for one resident with severe cognitive impairment was provided with accurate information regarding the risks and benefits of an antipsychotic medication. The resident, who had diagnoses including dementia, deafness, cognitive communication deficit, and major depressive disorder, was determined to lack capacity to make health care decisions, and the HCP was invoked. The resident was prescribed Seroquel, an antipsychotic, for symptoms such as agitation and delusional thinking. Upon review, the informed consent form signed by the HCP listed the purpose of the medication as treatment for major depressive disorder and included risks and benefits associated with antidepressant medications, not antipsychotics. Interviews with nursing staff confirmed that Seroquel is an antipsychotic and that the consent form contained incorrect information regarding the medication's risks and benefits. This error resulted in the HCP not being fully informed about the specific risks and benefits of the antipsychotic medication being administered.
Failure to Assess Foam Wedges as Potential Restraint
Penalty
Summary
The facility failed to assess the use of foam wedges as a potential physical restraint for a resident with severe cognitive impairment, dementia, legal blindness, deafness, and schizophrenia. The resident was identified as a high fall risk, with a history of attempting to crawl out of bed and tossing legs over the side. Observations showed the resident in bed with foam wedges on both sides, and documentation indicated the wedges were used as a fall intervention. However, there was no evidence in the resident's assessments that a restraint assessment had been completed for the use of these foam wedges. Interviews with nursing staff, the unit manager, and the DON confirmed that the foam wedges were used as a fall prevention measure, but staff had not conducted a restraint assessment for their use. Additionally, the facility was unable to provide a policy related to restraints. The lack of a restraint assessment and policy for the use of foam wedges constituted the deficiency identified during the survey.
Failure to Develop Comprehensive Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a cardiac pacemaker. According to the facility's own policy, specific information regarding the pacemaker—including the cardiologist's contact information, type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, and paced rate—should be documented in the medical record and on a pacemaker identification card upon admission. However, a review of the resident's electronic and paper medical records, as well as physician's orders and care plans, revealed that none of this required information was present. The resident had a history of acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, and the presence of a cardiac pacemaker, and was assessed as having intact cognition. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, confirmed that the resident's medical record lacked essential pacemaker-related information. Staff acknowledged that the care plan should have included details such as the serial number, type of device, paced rate, cardiologist information, and a method for monitoring and transmitting pacemaker data to the appropriate physician. The absence of this information constituted a failure to meet the facility's policy and regulatory requirements for comprehensive care planning for residents with pacemakers.
Failure to Implement Medication Orders and Specify Air Mattress Settings
Penalty
Summary
The facility failed to follow professional standards of nursing practice for two residents. For one resident with dementia and dysphagia, a nurse practitioner documented an as-needed order for Zofran to address nausea and vomiting. However, review of the physician's orders and medication administration record showed that the order for Zofran was not implemented. Nursing staff did not enter the order, and the unit manager was unaware of the nurse practitioner's note. The resident subsequently experienced further gastrointestinal symptoms, including diarrhea and emesis, without the ordered medication being available. For another resident with chronic obstructive pulmonary disease, reduced mobility, and severe cognitive impairment, the facility did not specify the required settings for the resident's air mattress in the physician's order, despite the resident being at high risk for pressure ulcers. Observations showed the air mattress was set to certain firmness and cycle time levels, but the physician's order and care plan only indicated the need for an air mattress without detailing the appropriate settings. Interviews with nursing staff and management confirmed that the order should have specified the mattress settings to ensure proper care.
Failure to Communicate Provider Recommendations and Obtain Timely Specimens
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. For one resident with a history of extradural and subdural abscess, osteomyelitis, and sepsis, the infectious disease provider recommended discontinuing IV antibiotics and starting an oral antibiotic regimen. However, after the resident returned from the appointment, nursing staff did not notify the medical doctor or nurse practitioner of the new medication recommendation. As a result, no new order for the oral antibiotic was initiated, and the resident did not receive the recommended medication. Multiple staff interviews confirmed that the recommendation was not communicated, and the resident was not on any antibiotics at the time of the survey. For another resident with mild cognitive impairment, heart failure, and sensory deficits, a care plan meeting was held after a fall and increased confusion, leading to an order for a urine analysis with culture and sensitivity to test for a possible urinary tract infection. The order was documented in the paper record, but the urine specimen was not obtained over several days, as the resident remained in bed or was otherwise unavailable. Nursing notes repeatedly indicated the inability to collect the specimen, but there was no documentation that the nurse practitioner or physician was notified of the failure to obtain the sample. The resident subsequently experienced another fall, was sent to the emergency department for evaluation of mental status changes, and was treated for acute cystitis. Staff interviews confirmed that the lack of timely notification to the provider about the uncollected urine specimen was a deviation from expected practice. Both the unit manager and DON acknowledged that the provider should have been informed after a few days of unsuccessful attempts to collect the specimen, which might have prevented the resident's transfer to the emergency department.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident who was observed receiving supplemental oxygen therapy without a physician's order. The resident, admitted with acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, and a cardiac pacemaker, was noted multiple times over two days to be receiving oxygen via nasal cannula at varying flow rates. Despite these observations, there was no active physician's order for oxygen therapy in the resident's medical record, Kardex, or medication and treatment administration records. Facility policy requires verification of a physician's order prior to administering oxygen, and this was confirmed by interviews with nursing staff and facility leadership, all of whom acknowledged that an order is necessary. The resident's care plan referenced oxygen therapy as ordered, but no such order was present. Nursing progress notes documented the administration of oxygen, but this was not supported by a corresponding physician's order, indicating a failure to follow established protocols for respiratory care.
Failure to Regularly Inspect Bed Frames for Entrapment Risks
Penalty
Summary
The facility failed to regularly inspect bed frames to identify areas of potential entrapment, specifically in Zone 7 (the space between the mattress and the foot of the bed) for all 27 residents' beds. This deficiency was evidenced by the inadequate bed bolster provided for a resident with a traumatic brain injury and severe cognitive impairment. Observations revealed a visible gap between the bolster and the mattress, creating a potential entrapment risk. The resident's bed rail assessment and care plan did not address this entrapment zone, and the facility's documentation of bed inspections was outdated, with the most recent records from 2021. Interviews with the Maintenance Director and Unit Manager confirmed that bed entrapment checks were only conducted annually, and there was no recent documentation of these inspections. The Unit Manager acknowledged the inadequacy of the bolster and the entrapment risk it posed. The Administrator was unable to explain why the entrapment zone sheets had not been updated since 2021. This lack of regular inspection and documentation led to the failure to identify and mitigate the entrapment risk for the resident.
Incomplete MOLST Form for Resident
Penalty
Summary
The facility failed to accurately complete a Medical Orders for Life Sustaining Treatment (MOLST) form for a resident with diagnoses including deafness, blindness, and psychosis. The resident, represented by a legal guardian, had elected Do Not Resuscitate (DNR) status, along with Do Not Intubate or Ventilate, and Do Not Hospitalize. However, the MOLST form was found to be invalid as it lacked the required provider's signature in section H, which is necessary to verify the information accurately reflects the discussion with the guardian. This deficiency was identified during a review of the resident's medical records and confirmed in an interview with the Unit Manager.
Violation of Privacy and Confidentiality Policies
Penalty
Summary
The facility failed to ensure staff implemented policies and procedures related to personal privacy and confidentiality for one resident. Specifically, a Unit Manager used a personal cell phone to take a picture of the resident's wound, which is against the facility's Clinical Photography Policy. The policy states that clinical photography should only be done with a completed Photography Consent Form and should not be taken on personal devices. The resident's health care proxy had consented to clinical photography, but the use of a personal phone was a clear violation of the policy. During a clinical meeting, the Unit Manager showed the photo of the resident's wound to the Director of Nursing (DON) and offered to show it to the Administrator, who declined. The Unit Manager made a joke about her husband not liking to see such photos, which was witnessed by the Social Worker and other staff members. The Social Worker reported the incident to Human Resources (HR), who then brought it to the attention of the Administrator and the DON. Despite reviewing the unit cell phone, no photos of the wound were found, raising concerns about the use of personal devices for clinical photography. Interviews with various staff members, including the Social Worker, HR Staff Person, DON, Rehab Director, and the Administrator, confirmed the incident. The Unit Manager denied taking the photo on her personal phone and claimed she was joking about her husband. However, the Rehab Director and Social Worker believed the photo was on a personal phone, as the phone used was white, unlike the facility's black phones. The Administrator and DON assumed the photo was taken on the unit cell phone but could not find any evidence of it. The incident highlights a breach of the facility's policy and the need for strict adherence to privacy and confidentiality protocols.
Failure to Develop and Implement Care Plans
Penalty
Summary
The facility failed to develop and implement a care plan for two residents, leading to deficiencies in their care. For Resident #81, who was admitted in May 2021 with a diagnosis of post-traumatic stress disorder (PTSD), the facility did not develop a care plan addressing this diagnosis. Despite the resident's Minimum Data Set (MDS) assessment indicating an active diagnosis of PTSD, no written care plan was created. This was confirmed during an interview with Unit Manager #1, who acknowledged that a care plan should have been developed for the PTSD diagnosis. For Resident #3, who has severe cognitive impairment and is dependent on staff for all activities of daily living (ADLs), the facility failed to implement the falls care plan. The resident's care plan and Kardex indicated the need for fall mats on each side of the bed due to a history of rolling out of bed and lack of safety awareness. However, observations on multiple occasions revealed that fall mats were not present in the resident's room. Interviews with staff, including a Certified Nursing Assistant and Unit Manager #1, revealed that the fall mats were forgotten during a recent room change, and the care plan interventions were not followed.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to ensure the oxygen concentrator filter for a resident with asthma and congestive heart failure was free of significant dust. The resident, who was admitted in May 2021, had a care plan that did not reference their asthma or intermittent use of oxygen therapy. The resident's active physician orders required oxygen therapy to maintain blood oxygen saturation above 88%. The oxygen concentrator was last used on 3/4/24 for shortness of breath, and the resident had been hospitalized twice for shortness of breath in the past two months. On two separate occasions, the surveyor observed the resident's oxygen concentrator filter covered in dust. The Unit Manager was unaware of the dusty filter and stated that facility staff do not change or clean these filters, relying instead on a respiratory equipment vendor who visits weekly. The Administrator and Director of Nursing confirmed that the facility does not have a policy for oxygen concentrator filter maintenance and relies on the vendor for this task. They were unable to confirm the last time the filter was changed.
Failure to Maintain Safe Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that Resident #18's wheelchair was in safe operating condition. Resident #18, who has diagnoses including deafness, blindness, and psychosis, reported the wheelchair's poor condition to nursing staff and the Maintenance Director two to three months prior to the survey. The wheelchair was observed to be missing the upper left chair handle, had exposed metal edges, a broken and loosely attached right armrest, and a stretched and scratched sling back fabric. Despite these reports, no action was taken to repair or replace the wheelchair, causing discomfort to the resident. Interviews with the Unit Manager, Rehabilitation Director, and Maintenance Director revealed a lack of communication and responsibility regarding the maintenance of the wheelchair. The Unit Manager was unaware of the wheelchair's condition, and the Rehabilitation Director stated that it was the responsibility of the staff who were informed or observed the issue to report it to the Maintenance Director. The Maintenance Director confirmed that he had not been informed about the wheelchair's condition and had not made any repairs. The Rehabilitation Director assessed the wheelchair and determined it needed to be replaced due to its broken components and age.
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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