North End Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 70 Fulton Street, Boston, Massachusetts 02109
- CMS Provider Number
- 225506
- Inspections on file
- 24
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at North End Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A nurse with an expired CPR certification failed to immediately start CPR on a full code resident found unresponsive and pulseless, instead leaving the resident with a CNA while calling 911 and retrieving emergency equipment. The CNA did not begin CPR, resulting in a delay of life-saving measures, contrary to facility policy and AHA guidelines.
A nurse assigned to a full code resident was not current in CPR certification and had not completed the required annual CPR competency. When the resident was found unresponsive, the nurse initiated CPR and called 911, but emergency responders determined the resident may have expired about an hour earlier. The DON was unaware of the expired certification, and no mock code drills had been conducted in the past year. An audit during survey also found another nurse with an expired CPR certification.
Nursing staff did not consistently label and date enteral free water administration bags and tube feeding bottles, and in several cases, the amount of tube feeding administered did not match physician orders. Multiple residents with conditions such as malnutrition, dysphagia, and ventilator dependence were affected, with observations showing unlabeled bags and bottles and discrepancies in administered volumes. Facility policies lacked clear instructions on labeling, and the DON confirmed that proper labeling and adherence to orders were expected.
Two residents with cardiac pacemakers did not have individualized, comprehensive care plans that included required details such as device information, implant date, paced rate, frequency of checks, or cardiologist contact information. Nursing staff were unclear about the need to include these specifics, and the DON confirmed these omissions did not meet facility policy.
Two residents requiring ventilator or tracheostomy care did not receive respiratory tubing changes in accordance with physician orders or facility policy. Tubing was observed to be in use beyond the recommended interval, and staff interviews revealed inconsistent adherence to established protocols for changing respiratory equipment.
Staff failed to secure medication and treatment carts, leaving them unlocked and unattended on a unit. The surveyor was able to access these carts multiple times without staff intervention, despite staff walking by or being nearby. Facility policy and interviews confirmed that carts should be locked at all times when not in use.
Two residents experienced inaccurate medical record documentation: one had ventilator tubing changes recorded that did not occur, and another had conflicting tube feeding orders with nurses signing for both time frames. The DON confirmed that documentation did not accurately reflect care provided.
A resident with multiple comorbidities and severely impaired cognition, who was a full code, was found unresponsive and later pronounced deceased. The nurse who responded had an expired CPR certification and delayed initiating CPR while calling 911 and retrieving the crash cart. The DON was unaware of the expired certification and did not investigate the incident or complete required code documentation. The facility's process for reviewing unexpected deaths was not followed, and a subsequent audit revealed another staff member with an expired CPR certification.
The facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for a resident with severe cognitive impairment. The resident was observed multiple times with pillows tucked under the fitted sheet to prevent rolling out of bed, but no restraint assessment was documented. The ADON and DON confirmed that this practice could be considered a restraint and that no assessment had been conducted.
The facility failed to develop and implement a care plan for a resident with an implantable cardioverter defibrillator (ICD). The resident's clinical record lacked information about the ICD, and the ADON was unaware of its presence, indicating a lapse in communication and documentation.
The facility failed to address suicide threats for a resident with severe cognitive impairment and did not follow a physiatrist's recommendations for therapy evaluations for another resident with Alzheimer's and a history of falling. These lapses indicate a failure to meet professional standards of nursing practice.
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment, inaccurately documenting the replacement of a suprapubic catheter. The Director of Nurses confirmed that the facility staff do not perform these changes, and the resident goes to urology for the procedure.
Delayed CPR Initiation Due to Nurse's Actions and Lapsed Certification
Penalty
Summary
A deficiency occurred when a nurse failed to immediately initiate cardiopulmonary resuscitation (CPR) for a resident who was a full code and found unresponsive with no pulse. The nurse, whose CPR certification had expired, discovered the resident without signs of breathing or a pulse during a routine check. Instead of starting CPR right away, the nurse left the resident with a CNA, who was not instructed to begin CPR, while he went to call 911, page a code blue, and retrieve the crash cart. This sequence of actions resulted in a delay in the initiation of life-saving measures. Facility policy and American Heart Association guidelines require that CPR be started immediately upon finding an unresponsive individual with no pulse, unless a do-not-resuscitate (DNR) order is in place. The nurse did not follow these protocols, as he prioritized calling for help and gathering equipment over starting chest compressions. The CNA present did not begin CPR and was told to wait for the nurse to return. The Director of Nursing confirmed that the expectation was for the nurse to start CPR while the CNA called for help and retrieved equipment, but this did not occur. The resident involved had significant medical conditions, including chronic kidney disease, hypertension, and type 2 diabetes, and was documented as having severely impaired cognition. The resident was last seen alive a few hours before being found unresponsive. Emergency medical services arrived to find the resident with signs of prolonged downtime and pronounced the resident deceased. The nurse renewed his CPR certification approximately one month after the incident.
Failure to Ensure Nurse CPR Competency and Certification
Penalty
Summary
The facility failed to ensure that a nurse assigned to care for a resident with full code status was competent and certified to perform Cardiopulmonary Resuscitation (CPR) at the time of an emergency. The resident, who had severely impaired cognition and was unable to participate in a mental status exam, was found unresponsive and without a pulse. The nurse on duty initiated CPR and called 911, but it was later determined by emergency responders that the resident may have expired about an hour prior to their arrival. Review of records showed that the nurse's CPR certification had expired six months before the incident, and there was no documentation of completion of the required annual CPR competency. Interviews revealed that the Director of Nursing (DON) was unaware of the nurse's expired certification and acknowledged that the facility had not conducted any mock code drills in the past year, contrary to their stated policy. The DON also indicated that responsibility for tracking staff competencies and CPR recertification had lapsed due to recent staff departures in both the staff development and human resources departments. An audit conducted during the survey identified another nurse with an expired CPR certification. The Medical Director stated that it is expected for both the facility and individual nurses to ensure timely renewal of CPR certifications.
Failure to Label and Administer Enteral Feedings per Physician Orders
Penalty
Summary
Nursing staff failed to adhere to professional standards of practice for the administration of free water flushes and enteral tube feeding for six out of seven residents observed with tube feeds. Specifically, staff did not consistently label and date enteral free water administration bags and tube feeding bottles, as required for safe administration and monitoring. In several cases, the amount of tube feeding administered did not match the physician's orders, indicating a lack of compliance with prescribed nutritional regimens. For example, one resident with protein-calorie malnutrition, ventilator dependence, and muscle wasting had a water bag for free water flushes that was not labeled with the date hung. Another resident, also with protein-calorie malnutrition and ventilator dependence, had both an unlabeled water administration bag and discrepancies between the amount of tube feeding administered and the physician's order. Additional residents with diagnoses such as dysphagia, Alzheimer's disease, Guillain-Barre Syndrome, and amyotrophic lateral sclerosis were observed with either unlabeled tube feeding bottles, unlabeled free water administration bags, or both. In multiple instances, the volume of tube feeding delivered did not correspond to the prescribed rate and duration, as evidenced by the remaining volume in the bottles and the time elapsed since they were hung. The facility's policies on enteral nutrition and safety precautions did not specify requirements for labeling and dating tube feeding and free water administration bags, contributing to inconsistent practices among staff. During interviews, the DON confirmed that all enteral free water administration bags and tube feeding bottles should be labeled with the date, time hung, and prescribed rate of flow, and that nurses are responsible for ensuring the correct amount is administered as ordered. The observed deficiencies were based on direct observations, record reviews, and staff interviews.
Failure to Develop Comprehensive Pacemaker Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with cardiac pacemakers. For one resident with chronic obstructive pulmonary disease and a pacemaker, the care plan did not include essential pacemaker information such as the make, model, serial number, implant date, paced rate, frequency of pacemaker checks, or cardiologist contact details. The resident was dependent on staff for daily activities and had an active diagnosis of a cardiac pacemaker, but the care plan lacked the required documentation and monitoring details as outlined in the facility's own policy. Similarly, another resident with an atrioventricular block and a pacemaker did not have a care plan that included the cardiologist's information, paced rate, or frequency of pacemaker checks. Interviews with nursing staff revealed uncertainty about the need to include specific pacemaker information in care plans, and the DON confirmed that such details should be present. The facility's failure to document and plan for the monitoring and care of residents with pacemakers was identified through record review and staff interviews.
Failure to Adhere to Respiratory Tubing Change Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care in accordance with professional standards of practice for two residents who required ventilator or tracheostomy care. For one resident with severe cognitive impairment and total dependence for activities of daily living, the tracheostomy tubing in use was observed to be dated more than three weeks prior, despite facility policy requiring tubing changes every seven days or as needed. There was no physician's order specifying the frequency of tubing changes for this resident, and staff interviews confirmed that tubing was changed on a set weekly schedule, not necessarily aligned with policy or physician orders. For another resident, also severely cognitively impaired and dependent on staff, ventilator tubing was observed to be in use beyond the weekly change interval specified in the physician's order. The care plan for this resident directed staff to keep respiratory equipment clean and change disposable equipment per facility policy, but the observed practice did not align with these directives. Interviews with staff and the DON confirmed that respiratory tubing should be changed per physician order or, if absent, per facility policy, but this was not consistently followed.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with State and Federal requirements, as well as the facility's own policy. Multiple observations were made on the fourth floor where medication and treatment carts were left unlocked and unattended. Specifically, a medication cart was found unlocked in the hallway without a nurse present, and the surveyor was able to access its drawers for four minutes without staff intervention. During this time, other staff members, including a certified nurse's aide and another staff member, passed by without addressing the unsecured cart. Additionally, several treatment carts were observed unlocked and unattended near the nurse's station and in the hallway. The surveyor was able to access these carts without interference, and staff, including the Admissions Director, walked by the unlocked carts multiple times without securing them. Interviews with nursing staff and the Director of Nursing confirmed that only authorized personnel should have access to these carts and that they are required to be locked at all times when not in use.
Inaccurate Medical Record Documentation for Respiratory and Enteral Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident with severe cognitive impairment and ventilator dependence, the respiratory administration record indicated that ventilator tubing was changed on specific dates, but observation revealed the tubing had not been changed as documented. The respiratory therapist stated that tubing changes occurred weekly on Sundays, which did not align with the documentation. The Director of Nursing confirmed that documentation should only reflect actual changes performed according to physician orders. For another resident who was cognitively intact and dependent on staff for all activities of daily living, there were conflicting physician orders for enteral feeding times. The medication administration record showed that nurses signed off on both conflicting orders over several days, indicating inaccurate recordkeeping regarding the timing of tube feedings. The Director of Nursing acknowledged that only one time frame should have been documented, and the presence of conflicting orders led to inaccurate documentation.
Failure to Investigate and Monitor Adverse Event Following Resident Death
Penalty
Summary
The facility failed to implement effective adverse event monitoring and investigation processes, specifically in the case of a resident with chronic kidney disease, hypertension, and type 2 diabetes who was a full code. The resident, who had severely impaired cognition and could not participate in mental status exams, was found unresponsive and pulseless. The nurse on duty, whose CPR certification had expired six months prior, left the resident with a certified nursing aide to call 911, initiate a code blue, and retrieve the crash cart before starting CPR. Emergency responders later determined the resident may have expired about an hour before being found. The Director of Nursing (DON) was unaware that the nurse's CPR certification was expired and stated that responsibility for tracking certifications belonged to the Staff Development Coordinator and Human Resources, both of whom had recently left the facility. The DON had assumed their duties but had not yet filled the positions. Although a code sheet system was reportedly implemented to document code events, the sheet was not completed for this incident, and the DON did not conduct an investigation, stating that nothing in the medical record warranted further review. The DON was also unaware that CPR was not initiated immediately. The Administrator confirmed that the facility's process for unexpected deaths of full code residents included completing a code sheet and review by the DON and physician, but this was not done in this case. The Medical Director expected all staff to be recertified in CPR every two years and was notified of the incident, noting the death was not expected as the resident was not on hospice. During a facility-wide audit conducted during the survey, another staff member was found to have an expired CPR certification.
Failure to Assess Use of Pillows as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including dementia, spinal stenosis, and anxiety disorder, was observed multiple times with pillows tucked under the fitted sheet on both sides of the bed. This practice was intended to prevent the resident from rolling out of bed, as noted by a Certified Nursing Assistant (CNA). However, there was no documentation in the resident's medical record or plan of care indicating that a restraint assessment had been completed for this intervention. During interviews, the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) confirmed that the use of pillows in this manner could be considered a restraint and that no assessment had been conducted. The facility's policy on the use of restraints requires a pre-restraining assessment and review to determine the need for restraints, which was not followed in this case. The DON also stated that staff had not been instructed to use pillows in this way for the resident.
Failure to Develop and Implement Care Plan for Resident with ICD
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with an implantable cardioverter defibrillator (ICD). The resident, who was admitted with diagnoses including end-stage renal disease and chronic systolic heart failure, had an ICD placed prior to admission. However, the clinical record did not include any information related to the ICD, nor did it contain a care plan with individualized interventions or methods for staff to monitor or identify the ICD. During an interview, the Assistant Director of Nursing (ADON) acknowledged that all information related to internal defibrillators should be included in the resident's record. The ADON was unaware that the resident had an internal defibrillator, indicating a lapse in communication and documentation within the facility. This oversight led to the deficiency noted in the report.
Failure to Address Suicide Threats and Follow Therapy Recommendations
Penalty
Summary
The facility failed to meet professional standards of nursing practice for two residents. For Resident #18, who was admitted with diagnoses including major depressive disorder and psychotic disorder with delusions, the facility did not address suicide threats in a timely manner. The resident, who had a severe cognitive impairment, expressed suicidal intentions to the surveyor. Despite the facility's policy requiring immediate action, the Unit Manager dismissed the threats and did not inform the Director of Nurses or other relevant staff. This failure to act appropriately was confirmed during interviews with the Director of Nurses and other staff members, who stated that the resident should have been placed under one-to-one supervision and assessed by a Psychiatric Nurse Practitioner immediately after the threats were made. For Resident #3, who was admitted with diagnoses including Alzheimer's disease and a history of falling, the facility failed to follow the recommendations from a physiatrist for physical therapy and occupational therapy evaluations. The physiatrist had recommended these evaluations due to the resident's ongoing functional decline. However, the medical record showed that the recommendations were not communicated to the rehabilitation staff, and the resident was not receiving the necessary rehabilitation services. The Director of Nurses confirmed that the request for therapy evaluations was not acted upon, indicating a lapse in communication and follow-through on critical medical recommendations.
Inaccurate Documentation of Suprapubic Catheter Changes
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment who had a suprapubic catheter. The resident's medical records inaccurately documented the replacement of the suprapubic catheter, indicating it was changed 23 times in February and three times in March, which was not the case. The Director of Nurses confirmed that the facility staff do not perform suprapubic catheter changes and that the resident goes to urology for these procedures. The resident was admitted with diagnoses including muscle wasting, benign prostate hyperplasia, and urinary retention. The resident's care plan and physician's orders specified monthly catheter changes, but the documentation did not reflect the actual practice. The discrepancy was noted during a surveyor's observation and subsequent review of the resident's records and progress notes, which indicated that the catheter was changed at an external urology appointment, not by the facility staff as documented.
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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