Northwood Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 1010 Varnum Avenue, Lowell, Massachusetts 01854
- CMS Provider Number
- 225298
- Inspections on file
- 23
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Northwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Two residents in the facility did not receive adequate pressure ulcer care, leading to deficiencies in treatment and prevention. One resident developed a deep tissue injury on the right heel, and despite recommendations from a wound physician, the facility failed to implement necessary treatments like skin prep every shift and a pressure off-loading boot. Another resident with a long-standing pressure wound on the left heel did not receive the recommended offloading measures. Observations and staff interviews confirmed the lack of appropriate interventions, highlighting a failure in communication and execution of care plans.
A resident with Alzheimer's and major depression did not receive necessary behavioral health services and psychotropic medications as ordered. Recommendations for medications like Remeron, Ativan, and Depakote were not communicated to the physician, and the resident's Trazadone and Risperidone were discontinued without authorization, leading to increased behavioral issues. Staff interviews revealed communication lapses and inadequate follow-up on the resident's care needs.
The facility failed to maintain adequate staffing levels to meet residents' personal care needs, as outlined in their staffing plan. Despite having a detailed staffing plan, the facility did not meet the required hours per patient per day for nursing staff and CNAs on multiple occasions. Corporate Nurse #1 acknowledged the issue, citing new leadership and a lack of awareness as contributing factors.
The facility failed to ensure accurate documentation and maintain complete medical records for several residents. A resident with an AV fistula had blood pressure readings inaccurately documented from the wrong arm. Another resident's MOLST form was unsigned, and their MDS was inaccurately coded. Additionally, a resident's use of multipodus boots was not properly documented, and another resident's blood pressure was taken from an arm with dialysis access, contrary to orders.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident with Alzheimer's and Major Depressive Disorder had a Health Care Proxy that was not invoked, yet consent for Trazadone was signed by the proxy. Another resident with severe cognitive impairments was given Lorazepam and Mirtazapine without documented consent. Staff interviews confirmed that consents should be obtained on admission, annually, and when new medications are started.
A resident with COPD and sleep apnea experienced a malfunctioning CPAP machine, which was not reported to a physician or provider by the facility staff. Despite the resident's complaints and visible error codes on the machine, there was no documentation of notification to healthcare providers. Interviews revealed communication lapses among staff, leading to a delay in ordering a replacement machine.
The facility failed to secure resident PHI on a nursing unit. On two occasions, nurses left medication carts unattended with computer screens open, displaying electronic health records in the hallway. The nurses acknowledged the oversight, and the DON confirmed that screens should be locked when unattended.
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months due to a drainage issue. Residents and a family member expressed frustration over the inconvenience and impact on quality of life. The Maintenance Director admitted to not starting necessary repairs, awaiting authorization, and expressed reluctance to reopen the bathroom without further system flushing.
The facility failed to implement personalized care plans for two residents, leading to deficiencies in care. One resident did not receive physician-ordered multipodus boots, despite being at high risk for pressure ulcers, and there was no documentation of refusal. Another resident with hearing loss and dementia lacked a care plan for hearing deficits, despite documented difficulties. Staff interviews revealed a lack of awareness and documentation, indicating a failure to adhere to facility policies.
A resident with heart failure and muscle weakness did not receive scheduled showers for over five months, despite facility policy requiring weekly showers. The resident, who has intact cognition, reported only having two showers since admission. Staff interviews confirmed the expectation of weekly showers, but there was no documentation of refusal in the resident's medical chart.
The facility failed to change a diabetic resident's wound dressings daily as ordered, resulting in discolored and odorous dressings. Additionally, the facility did not notify a physician of significant weight changes in a resident with congestive heart failure, despite orders to do so. Both deficiencies indicate lapses in following physician orders and monitoring protocols.
The facility failed to address significant weight changes in three residents, including a resident with a 14.63% weight loss, another with an 8.24% weight gain, and a third with a 13.35% weight loss. Nutritional interventions were not implemented for the first resident due to hospice status, educational interventions were not attempted for the second resident despite diabetes, and the third resident was not reweighed after a significant weight loss. The facility's policies on weight monitoring and intervention were not followed.
The facility failed to provide proper respiratory care for two residents. One resident did not have physician's orders for CPAP settings, and their CPAP machine was not functioning, leading to restless nights. Another resident's oxygen administration lacked a specific flow rate in the physician's orders. Staff interviews confirmed these deficiencies.
The facility failed to ensure emergency supplies, including a non-serrated clamp, were available at the bedside for two residents receiving hemodialysis. One resident with end-stage renal disease confirmed the absence of emergency supplies in their room, which was verified by inspection. Another resident, also receiving dialysis through a chest port, was observed without a clamp at the bedside. The DON acknowledged the policy requirement for maintaining a clamp in the rooms of residents receiving dialysis.
A facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, despite having a policy requiring such plans. The resident, with diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, had specific triggers related to discharge discussions that were not addressed in the care plan. Staff interviews confirmed the absence of a trauma care plan, which should have been in place.
A nurse in an LTC facility made five medication errors out of 26 opportunities, resulting in a 19.23% error rate. The errors affected a resident, with medications administered over two hours late and Metformin not given with breakfast as ordered. The nurse acknowledged the timing errors, and the DON confirmed the policy of administering medications within one hour of the scheduled time.
The facility failed to label and store medications according to professional standards, with two medication carts containing opened and undated medications. Additionally, unlicensed personnel were left unsupervised in the medication room, contrary to facility policy. The DON confirmed that nurses are responsible for dating medications and supervising non-nursing staff in the medication room.
The facility failed to follow infection prevention protocols, as a nurse and CNA did not wear precaution gowns during a dressing change for a resident on enhanced barrier precautions (EBP). Additionally, the nurse did not perform hand hygiene between glove changes, citing a lack of hand sanitizer. These actions were contrary to the facility's policies on EBP and hand hygiene.
A facility failed to maintain accurate medical records for a diabetic resident with a history of foot wounds. Despite physician orders to monitor and evaluate the resident's feet, the Treatment Administration Record repeatedly marked foot care as 'Not Applicable' without documenting the resident's refusal of care. Staff interviews confirmed the resident often refused foot care, but these refusals were not recorded, contrary to facility policy.
Failure to Implement Pressure Ulcer Care Recommendations
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in their treatment and prevention of new ulcers. Resident #108, who was at high risk for developing pressure ulcers, developed a deep tissue injury on the right heel while in the facility. Despite recommendations from a consultant wound physician, the facility did not implement the necessary treatments, such as applying skin prep every shift and using a pressure off-loading boot. Observations showed that Resident #108's heels were often directly on the mattress, and the air mattress settings were not adjusted according to the care plan, potentially compromising the effectiveness of pressure relief. Resident #100, who had a pressure wound on the left heel for over 210 days, also did not receive the recommended care. The facility failed to ensure the use of a pressure off-loading boot and did not consistently offload the resident's heels from the mattress. Despite clear orders and recommendations from the wound physician, the necessary interventions were not in place, and staff interviews confirmed the lack of appropriate offloading measures. The facility's policies on consultant services and pressure injury management were not followed, as evidenced by the lack of timely implementation of the wound physician's recommendations. Interviews with staff, including the Director of Nursing, highlighted a failure in communication and execution of care plans, contributing to the worsening of pressure areas for both residents. The deficiencies observed indicate a significant lapse in adhering to professional standards of practice for pressure ulcer care.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with Alzheimer's Disease, major depression, and unspecified dementia with behavioral disturbances. The resident was admitted with prescriptions for Risperidone and Trazadone, but the facility did not implement recommendations from the Psychiatric Nurse Practitioner or ensure that psychotropic medications were administered as ordered. The resident exhibited increased agitation, aggression, and other behavioral issues, which were not adequately addressed by the facility's staff. The facility's policy required that recommendations from health care consultants be communicated to the attending physician for approval and implementation. However, the recommendations to initiate Remeron, Ativan, and Depakote were not relayed to the physician, and the medications were not administered. Additionally, the resident's Trazadone and Risperidone were discontinued without authorization, leading to a period where the resident was without necessary psychotropic medications, exacerbating their behavioral issues. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's behavioral health needs. The Psychiatric Nurse Practitioner and nursing staff were unaware that the recommended medications were not administered, and the Director of Nursing was not informed of the discontinuation of the resident's medications. The facility's failure to adhere to its policies and ensure proper medication management contributed to the resident's ongoing behavioral disturbances and incidents of aggression.
Staffing Deficiency in Nursing Home
Penalty
Summary
The facility failed to maintain sufficient staffing levels to adequately meet the personal care needs of its residents. The staffing plan outlined in the Facility Assessment included a variety of nursing roles such as a Director of Nursing, Assistant Director of Nursing, unit managers, and a weekend supervisor. However, the position for the second shift supervisor was open, indicating a gap in leadership during that shift. The staffing plan also detailed the number of nurses and certified nursing assistants (CNAs) required per shift, with specific ratios for each shift. Despite this plan, the facility's HPPD (hours per patient per day) report revealed that the facility did not meet the appropriate staffing levels for 23 out of 91 days from January through March 2024, and for 26 out of 92 days from May through July 2024. During an interview, Corporate Nurse #1 acknowledged the staffing issues, attributing them to new leadership and a lack of awareness of the problem. The facility's failure to meet the budgeted hours for both nursing staff and CNAs on numerous occasions suggests a systemic issue in maintaining adequate staffing levels. This deficiency in staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfall.
Inaccurate Documentation and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for several residents, leading to multiple deficiencies. For Resident #46, the staff inaccurately documented that blood pressures were taken from the left arm, despite the resident having an AV fistula in that arm, which should not be used for such procedures. This was confirmed by the resident and the Director of Nursing, who emphasized the importance of accurate documentation to prevent potential harm. Resident #80's medical record was incomplete and inaccurately coded. The facility failed to maintain a valid MOLST form, as it lacked the necessary signature from the resident or their responsible party. Additionally, the Health Care Proxy activation form was incomplete, and there was no physician order to invoke the HCP. The MDS was inaccurately coded regarding the resident's advanced directive status, and the medical record lacked physician notes, which are essential for a complete medical record. For Resident #16, the facility did not accurately document the use of multipodus boots, which are crucial for pressure ulcer prevention. Observations showed the resident was not wearing the boots as ordered, yet the nursing progress notes and MAR indicated otherwise. Similarly, for Resident #53, the staff documented blood pressure readings from the left arm, which had a dialysis access, contrary to the physician's orders and care plan. The DON confirmed that such documentation was inaccurate and against the facility's policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for two residents. Resident #80, who was admitted in June 2024 with diagnoses including Alzheimer's disease and Major Depressive Disorder, had a Health Care Proxy (HCP) on file that had not been invoked by a physician. Despite this, a consent for the psychotropic medication Trazadone was signed by the resident's designated HCP. The clinical record did not indicate that Resident #80 consented to the administration of Trazadone or had deferred to the HCP to sign on their behalf. Interviews with facility staff confirmed that the HCP should not be activated until a physician completes the necessary activation form and writes an order, and until then, the resident should sign their own consents. Resident #98, admitted in April 2023 with severe cognitive impairments and diagnoses including metabolic encephalopathy, bipolar disorder, and PTSD, was administered psychotropic medications Lorazepam and Mirtazapine without documented informed consent. The resident's medical record lacked evidence of psychotropic consent for these medications, which were administered according to physician orders. Interviews with nursing staff revealed that psychotropic medication consents are expected to be obtained upon admission, annually, and when new psychotropic medications are initiated, but this protocol was not followed for Resident #98.
Failure to Notify Provider of Malfunctioning CPAP Machine
Penalty
Summary
The facility failed to notify a physician or provider about a malfunctioning Continuous Positive Airway Pressure (CPAP) machine for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine had not been functioning since 8/18/24, causing restless nights and fatigue. Despite the resident's complaints and the visible error code on the machine, the facility did not document any notification to a healthcare provider about the issue. Interviews with facility staff revealed a lack of communication and documentation regarding the malfunctioning CPAP machine. The Assistant Director of Nurses (ADON) acknowledged the need to inform a provider and document the issue, but this was not done. The Nurse Practitioner was unaware of the problem, and the Admissions Director indicated a delay in ordering the replacement machine due to missing information. The Director of Nurses confirmed that the nursing staff should have notified a physician or Nurse Practitioner and documented the situation in the medical record.
Failure to Secure Resident PHI on Nursing Unit
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on one of its nursing units. On two separate occasions, a nurse on the A unit left her medication cart unattended with the computer screen open, displaying the electronic health record in the hallway. This occurred on the morning of August 27, 2024, when the nurse was preparing and administering medications. During an interview, the nurse acknowledged that she should have locked the computer screen to prevent PHI from being visible when she walked away. A similar incident occurred on August 28, 2024, when another nurse on the A unit left her medication cart unattended with the computer screen open, exposing PHI. The Director of Nurses confirmed in an interview that nurses are expected to close or lock computer screens when they leave them unattended to protect resident information.
Facility Fails to Provide Access to Main Floor Bathroom
Penalty
Summary
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months. During a Resident Group Meeting, residents expressed their frustration over the inconvenience caused by the bathroom's unavailability, as they have to return to their units during meals to use the restroom. A family member also highlighted the negative impact on residents' quality of life, as they may miss meals and activities due to the need to go back upstairs. The Maintenance Director revealed that the bathroom was kept out of service due to a drainage issue, not a cracked toilet as residents were told. Despite having vendors clear the blockage in May, the bathroom remained closed to prevent potential re-clogging by certain residents. The Nursing Home Administrator acknowledged a significant plumbing issue that caused flooding but deferred to the Maintenance Director for repair status. The Maintenance Director admitted to not starting the process of obtaining quotes for necessary repairs, awaiting authorization from the Regional Director, and expressed reluctance to reopen the bathroom without further system flushing.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement a resident-centered personalized care plan for two residents, leading to deficiencies in their care. For Resident #16, who was admitted with diagnoses including cerebral infarction and chronic leg syndrome, the facility did not implement the use of multipodus boots as ordered by the physician. Despite the resident being at high risk for pressure ulcers, observations over several days showed that the resident was not wearing the boots, which were instead found on the windowsill. The nursing progress notes did not document any refusal by the resident to wear the boots, and staff interviews revealed a lack of awareness and documentation regarding the resident's use of the boots. For Resident #105, who was admitted with conductive hearing loss and dementia, the facility failed to develop a care plan addressing the resident's hearing deficits. The resident's MDS assessment indicated severe cognitive deficits and an active diagnosis of bilateral conductive hearing loss. During an interview, the resident did not respond to questions, indicating difficulty hearing. A nursing progress note highlighted the resident's difficulty during a therapy session due to hearing issues, yet no care plan was developed to address this need. Staff interviews confirmed the absence of a care plan for the resident's hearing loss, which should have been implemented upon admission. These deficiencies highlight the facility's failure to adhere to its policies regarding the development and implementation of comprehensive care plans tailored to individual resident needs. The lack of proper documentation and communication among staff contributed to the oversight in providing necessary care and services to the residents, as outlined in the facility's policies.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #100, who was admitted in August 2023 with diagnoses including heart failure and muscle weakness. The facility's policy on Activities of Daily Living (ADL) requires that residents receive assistance to maintain or restore maximum functional independence, with a program of assistance developed based on individual evaluations. Despite this policy, Resident #100, who has intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, reported not having taken a shower in over six months. The resident's care plan, last revised in July 2024, indicated a need for substantial/maximal assistance with showering, yet documentation showed no showers were provided in the last five months. Interviews with facility staff, including CNAs and a nurse, confirmed that all residents are scheduled for weekly showers, and any refusals should be documented. However, there was no documentation in Resident #100's medical chart indicating any refusal of showers. The resident expressed a desire to have a full shower occasionally, despite discomfort due to nerve sensitivity. The Director of Nursing also confirmed that scheduled showers should be provided unless refused, yet the lack of documentation suggests a failure in adhering to the facility's policy and ensuring the resident's needs were met.
Failure to Follow Physician Orders for Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to ensure proper wound care for a resident with diabetes, as the daily dressing changes ordered by the physician were not performed. The resident, who was cognitively intact and required supervision for daily tasks, was observed with discolored and odorous dressings on both feet, which had not been changed as per the physician's orders. The Assistant Director of Nursing confirmed that all physician orders should be followed, and daily notes should be written for wound changes, indicating a lapse in adherence to these protocols. Additionally, the facility did not follow a physician's order for monitoring a resident with congestive heart failure. The resident, who had intact cognition and required maximal assistance for showering, had significant weight fluctuations that met the parameters for physician notification. However, there was no documentation indicating that the physician was informed of these changes. The Director of Nursing acknowledged that the physician should have been notified of the weight changes, but there was no evidence that this occurred, highlighting a failure in communication and monitoring processes.
Failure to Address Significant Weight Changes in Residents
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of three residents, leading to significant weight changes that were not properly addressed. Resident #66 experienced a total weight loss of 14.63% over four months, yet no nutritional interventions were implemented despite the facility's policy requiring such actions. The Registered Dietitian (RD) acknowledged the oversight, attributing it to the resident's hospice status, although the Director of Nursing (DON) confirmed that nutritional interventions should still be applied in such cases. Resident #86 experienced an 8.24% weight gain over three months, which was not addressed with appropriate educational interventions. The RD admitted to focusing primarily on weight loss and did not attempt to educate the resident due to their non-verbal and aphasic condition, despite the availability of translator services. The DON expressed concern over the lack of intervention, especially given the resident's diabetes diagnosis, which makes weight gain particularly concerning. Resident #34 was not weighed in July, and a significant weight loss of 13.35% was recorded in August without a reweigh to confirm accuracy. The RD noted the missing weight but did not follow up adequately, and the DON confirmed that reweighs are expected in such cases. The resident's CNA reported that the resident had a good appetite and did not refuse to be weighed, indicating a lapse in the facility's weight monitoring protocol.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident, the facility did not ensure that the physician's orders included settings for a Continuous Passive Airway Pressure (CPAP) machine, nor did they ensure that the CPAP machine was functioning and available for use. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, reported that the CPAP machine had not been functioning since a specific date and that the facility was responsible for obtaining a replacement. Despite being aware of the issue, the facility had not replaced the machine, leading to the resident experiencing restless nights and fatigue. For another resident, the facility failed to obtain a complete physician's order for oxygen administration that included an oxygen flow rate. This resident, who had moderate cognitive impairment and diagnoses including COPD and emphysema, was observed using oxygen via nasal cannula at a specific flow rate. However, the physician's orders did not specify the liter flow for oxygen administration, which was acknowledged by the nursing staff as a deficiency. The facility's policies for CPAP/BiPAP management and oxygen administration were not followed, as evidenced by the lack of specific orders and functioning equipment for the residents. Interviews with nursing staff and the Director of Nurses confirmed the deficiencies in the orders and the failure to replace the malfunctioning CPAP machine, which had been known for over a week.
Failure to Provide Emergency Supplies for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents who required such services. Specifically, the facility did not ensure that emergency supplies, including a non-serrated clamp, were available at the bedside for residents receiving hemodialysis. Resident #46, who has end-stage renal disease and requires dialysis, reported that there were no emergency supplies in their room. This was confirmed during an inspection of the room, where no clamp was found. The Director of Nursing acknowledged that the facility's policy requires a clamp to be maintained in the room of all residents receiving dialysis treatment. Similarly, Resident #51, who also has end-stage renal disease and receives dialysis through a central line in the chest, was observed without any emergency supplies or clamp at the bedside. Despite the care plan indicating the need for dialysis through a chest port, Nurse #7 confirmed that there was no clamp in the room and was unaware of any policy requiring one. The Director of Nursing reiterated the expectation that the dialysis policy, which includes maintaining an emergency clamp, should be followed.
Failure to Develop Trauma Informed Care Plan for Resident
Penalty
Summary
The facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, as required by their policy. The policy mandates that social services screen each resident for a history of trauma upon admission and document a trauma-informed care plan in the resident's medical record. However, for Resident #75, who has diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, no such care plan was documented. The resident had a history of trauma, which was known to the facility staff, and specific triggers related to discharge discussions were identified as exacerbating the resident's behaviors. Despite the resident's known trauma history and the identification of specific triggers, the care plan did not include any resident-specific interventions or triggers. Interviews with the social worker and the Director of Social Service confirmed that a trauma care plan should have been in place. The Director of Social Service acknowledged the absence of the care plan, attributing it to the resident not disclosing the trauma directly to her, despite the resident's previous disclosure of a significant trauma situation during a prior stay at the facility.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 19.23% error rate observed during a survey. Nurse #4 was responsible for five medication errors out of 26 opportunities, impacting one resident. The errors involved administering medications outside the prescribed one-hour window and failing to give Metformin with breakfast as ordered. Specifically, medications including Metformin, Metoprolol, Methocarbamol, Lantus insulin, and Colace were administered over two hours past the scheduled time. Resident #86, who was affected by these errors, had specific physician orders for medication administration times and conditions, such as taking Metformin with breakfast. During interviews, Nurse #4 acknowledged the failure to administer medications within the appropriate time frame and not adhering to the order to give Metformin with breakfast. The Director of Nurses confirmed the policy that medications should be administered within one hour of the scheduled time and that medications ordered with meals should be given accordingly.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to accepted professional standards of practice. Specifically, two of the four medication carts were found to contain medications that were opened and undated, contrary to the manufacturer's guidelines. In the A wing medication cart #1, the surveyor observed an opened and undated Symbicort inhaler, Advair diskus inhaler, Lispro insulin pen, and a bottle of prosource liquid protein, all of which require specific discard timelines after opening. Similarly, in the A wing medication cart #2, an opened and undated Incruse inhaler was found. Interviews with nursing staff, including Nurse #8 and Nurse #2, confirmed that the medications should have been labeled with open dates, and the Director of Nurses reiterated that the responsibility for dating medications lies with the nurse who opens them. Additionally, the facility failed to supervise unlicensed personnel in the medication room, which is against the facility's policy. Nurse #2 allowed a maintenance worker and a substance abuse counselor into the medication room and left them unsupervised. The Director of Nursing confirmed that only nurses are permitted in the medication room, and any other employees must be supervised by a licensed nurse at all times. This lack of supervision and adherence to medication storage protocols represents a significant deviation from the facility's policies and accepted professional standards.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to transmission-based precautions and proper hand hygiene practices, leading to deficiencies in infection prevention and control. Specifically, a nurse and a certified nursing assistant (CNA) did not don precaution gowns while caring for a resident on enhanced barrier precautions (EBP) during a pressure ulcer dressing change. Despite a sign indicating the requirement for gowns and gloves for high-contact activities, both staff members only wore gloves throughout the procedure. Interviews revealed a misunderstanding of the EBP requirements, with the CNA believing gown use was optional and the nurse acknowledging the oversight. Additionally, the nurse failed to perform hand hygiene between glove changes during the dressing change procedure. The nurse removed and donned new gloves multiple times without using hand sanitizer, citing the absence of hand sanitizer as the reason for this lapse. The Director of Nurses confirmed that hand hygiene should be performed each time gloves are removed and before donning new ones, as per the facility's hand hygiene policy.
Inadequate Documentation of Diabetic Foot Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with diabetes, who had physician orders to monitor and evaluate skin integrity on their feet. Despite having a physician's order to observe and care for the resident's feet, the Treatment Administration Record (TAR) for March 2024 repeatedly documented diabetic foot care as 'Not Applicable' (N/A) without supporting documentation of the resident's refusal of care. The facility's policies required documentation of the resident's condition and care provided, as well as documentation of any refusal of treatment, which was not adhered to in this case. The resident, admitted in October 2023, had multiple diagnoses including diabetes, end-stage renal failure, dementia, and a history of foot wounds. Interviews with facility staff, including a Unit Manager and a nurse familiar with the resident, confirmed that the resident often refused foot care. However, the staff failed to document these refusals in the medical record, as required by facility policy. The Director of Nurses acknowledged that the documentation should have reflected the resident's behavior and refusals, indicating that the use of 'N/A' was inappropriate for documenting the resident's foot care.
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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