Norwood Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwood, Massachusetts.
- Location
- 460 Washington Street, Norwood, Massachusetts 02062
- CMS Provider Number
- 225343
- Inspections on file
- 20
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Norwood Healthcare during CMS and state inspections, most recent first.
Nursing staff did not obtain or document weekly weights for a resident with multiple complex diagnoses, despite a physician's order and RD recommendation for weekly monitoring due to high sodium and diuretic use. Only one weight was recorded, and facility leadership was unaware of the missed orders until after the fact.
A resident with moderate cognitive impairment and an activated Health Care Agent (HCA) was moved to a new room without the HCA's consent or notification. The facility failed to provide written notice, the reason for the change, or the opportunity to appeal, as required by their procedures. Staff interviews revealed a lack of communication and documentation regarding the room change.
A facility failed to report an injury of unknown origin involving a resident to the DPH within the required timeframe. The resident, who had a bump on the head, was sent to the hospital for evaluation. Miscommunication between the Administrator and the former DON led to a 33-day delay in reporting the incident.
A resident with a history of serious medical conditions was found with a bump on their forehead, but the LTC facility failed to conduct a thorough investigation. The incident was not immediately investigated, and the Physical Therapy Aide who discovered the injury was not interviewed. Despite instructions from the Administrator, the former DON did not follow through with the investigation, and the facility's report lacked evidence of a timely and comprehensive investigation.
Two residents at the facility, both identified as at risk for falls, experienced falls without subsequent updates to their care plans. One resident, with conditions including dementia and deep vein thrombosis, was found on the floor but had no new interventions added to their care plan. Another resident, also with dementia, was found sitting on the floor, yet their care plan was not revised to address this behavior. Interviews revealed a lack of clarity among staff regarding responsibility for updating care plans, and the acting DON was unaware of the oversight.
The facility failed to employ a full-time Social Worker as required for facilities with more than 120 beds. Since July 2024, the facility had been using consulting Social Workers with limited hours, which did not meet the full-time requirement. Despite a job posting for a full-time position, the facility had not filled the role, resulting in inconsistent social work coverage.
The facility failed to maintain active, court-approved treatment plans for the administration of antipsychotic medications for two residents with severe cognitive impairments and legal guardians. Additionally, 19 out of 21 other residents requiring such plans did not have valid approvals. The administrator was unaware of the status of these plans, and the social worker responsible for tracking them was not full-time and did not handle guardianship issues.
The facility failed to maintain a comfortable temperature on the North Two unit, with temperatures recorded as low as 58 degrees Fahrenheit. Residents expressed discomfort, wearing extra clothing to stay warm. Despite reports to staff, no corrective action was taken until the surveyor's visit. The Regional Facility Engineer and Administrator acknowledged the issue, but the temperature remained below the required range.
The facility failed to maintain sanitary conditions for respiratory equipment for three residents, leading to improper storage and outdated tubing. A resident with quadriplegia had oxygen tubing on the ground, while another with COPD used a discolored nasal cannula. A third resident's nebulizer mask was found on the floor. Staff interviews confirmed non-compliance with storage and maintenance protocols.
A facility failed to provide trauma-informed care for a resident with a history of trauma, including major depression, anxiety, and psychotic disorder. Despite multiple evaluations identifying exposure to traumatic events, no individualized care plan was developed to prevent re-traumatization. The consultant social worker acknowledged the oversight, and the facility had not employed a full-time social worker for several months.
The facility failed to lock treatment carts containing drugs and biologicals when not supervised by a licensed nurse, as observed across three units. Despite the facility's policy requiring carts to be locked when unattended, multiple instances of unlocked and unattended carts were noted. Interviews with nursing staff confirmed the expectation for carts to be secured, highlighting a lapse in adherence to safety protocols.
The facility failed to follow food safety standards, as observed in the main kitchen's walk-in refrigerator where several food items were improperly labeled or not labeled at all. Items such as pasta salad, peeled cucumber, and cooked meats were either past their use-by dates or lacked date markings, contrary to the facility's policy and FDA Food Code. Interviews with the FSD and Regional FSD confirmed these practices did not meet expected standards.
The facility failed to maintain complete and accurate medical records for several residents. Physician visit notes were not uploaded timely, leading to incomplete records for two residents. Additionally, catheter sizes were inaccurately documented for two residents, and substance abuse assessments were missing from the records of residents diagnosed with substance abuse. These deficiencies were due to system glitches, lack of training, and failure to update records after external appointments.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in data analysis and PPE use. The Infection Preventionist did not evaluate surveillance data in real-time, leading to inaccuracies. Staff failed to use appropriate PPE for Enhanced Barrier Precautions when caring for residents with indwelling devices, and a nurse did not follow contact precautions for a resident with MRSA.
The facility failed to notify the physician of a dietitian's recommendation to change a resident's nutritional formula and did not inform the HCP of another resident's pressure injuries. This lack of communication led to deficiencies in care coordination and oversight.
The facility failed to create individualized care plans for two residents, one with chronic pain and another with a left arm contracture. Despite receiving pain medications, the first resident lacked a comprehensive pain management plan. The second resident, with a history of intracerebral hemorrhage and left arm contracture, did not have a care plan for contracture management, despite recommendations from occupational therapy. Interviews with facility staff confirmed these deficiencies.
A facility failed to meet professional standards of care for a resident with a central venous catheter (CVC) for medication infusions. The resident, admitted with MRSA infection and chronic renal disease, required specific CVC care, including flushing and changing connectors. However, the facility lacked proper orders and documentation for these tasks. Interviews revealed that dressing changes were done at dialysis, but other necessary orders were not implemented, indicating a significant deficiency in care practices.
A resident with severe cognitive impairment and left arm contractures did not receive proper contracture management due to the facility's failure to document range of motion, implement occupational therapy recommendations, and educate staff on the use of positioning devices. Observations showed incorrect use of devices like the foam carrot and elbow wedge, and staff interviews revealed a lack of awareness and training, compounded by the absence of physician's orders for these aids.
The facility failed to ensure a safe environment by leaving hazardous items unattended in a hallway accessible to residents with dementia. Additionally, a resident's medications and diabetic supplies were improperly stored in an open room, accessible to wandering residents, without a self-administration assessment or physician's order. Staff acknowledged these safety hazards.
A resident with a suprapubic catheter was observed with the drainage bag resting on the floor without a protective barrier, contrary to CDC guidelines and physician's orders. The bag was leaking urine, and the nurse acknowledged the infection control risk. The DON confirmed the care plan did not address this issue.
The facility failed to issue Notices of Transfer/Discharge for two residents with severe cognitive impairments and legal guardians when they were emergently transferred to the hospital. Despite multiple transfers due to medical issues, there was no documentation of notices being provided to the residents, their representatives, or the ombudsman.
The facility failed to issue Bed Hold Policy Notices to two residents with severe cognitive impairment and legal guardians upon their transfer to the hospital, as required by their policy. Despite being transferred for medical reasons, no written notices were provided, as confirmed by nursing staff.
A resident with severe cognitive impairment and a history of traumatic brain injury eloped from the facility during a supervised smoke break due to inadequate supervision. The resident was missing for nine days before being found at a hospital. The facility's policies on elopement and smoking supervision were not adequately followed, and no care plan was developed to address the resident's elopement risk.
A facility failed to ensure staff consistently followed a resident's Plan of Care for smoking safety, resulting in the resident smoking unsupervised. Additionally, the facility did not accurately assess the resident's elopement risk based on their history of substance abuse and psychosis, leading to inconsistent assessments and no care plan for elopement risk.
Failure to Obtain and Document Ordered Weekly Weights
Penalty
Summary
Nursing staff failed to obtain and document weekly weights for a resident as ordered by the physician and recommended by the Registered Dietician (RD). The facility's policy required weekly weights for four weeks following admission, with more frequent monitoring if ordered by a physician. The resident, who had a history of acute CVA, aphasia, heart failure, subarachnoid hemorrhage, and myocardial infarction, was admitted with high sodium levels and was on two diuretics, making weight monitoring clinically significant. The RD specifically recommended weekly weights due to these factors, and a physician's order was in place for this monitoring. Despite these orders and recommendations, the medical record showed that only one weight was documented during the required period, with no evidence that weights were obtained or recorded for the subsequent two weeks. Interviews with facility staff, including the RD, Evening Supervisor, and DON, revealed that they were unaware the weights had not been obtained as ordered. The DON confirmed that it was facility expectation for nurses to follow all physician orders and to notify the DON and provider if unable to do so, but this process was not followed in this case.
Failure to Notify HCA of Room Change
Penalty
Summary
The facility failed to ensure that a resident's Health Care Agent (HCA) received written notice and the reason for a room change. The resident, who had an activated HCA due to moderate cognitive impairment and other medical conditions such as bilateral pulmonary embolisms and dementia, was moved to a new room without the HCA's consent or notification. The facility did not provide the HCA with the opportunity to appeal the decision, as required by their procedures. Interviews with facility staff revealed a lack of communication and documentation regarding the room change. The Social Worker was unaware of the room change and could not locate the necessary paperwork in the resident's medical record. The Nursing Supervisor assumed the Social Worker had notified the HCA, while the Assistant Director of Nurses, acting as the Director of Nurses, was not aware of the room change. The facility's expectation is that residents and their responsible parties are notified and consent is obtained before any room change, which was not adhered to in this case.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The incident involved a resident who was observed with an injury of unknown origin, specifically a small bump on the head, which was identified by a Physical Therapy Aide and subsequently led to the resident being sent to the hospital for evaluation. Despite the facility's policy requiring immediate reporting of such incidents, the report was not submitted to DPH until 33 days later. The deficiency occurred due to a lack of communication and follow-through between the facility's administration and nursing staff. The former Director of Nurses (DON) was unaware of the specifics of the injury and did not submit the report, believing the Administrator was handling the situation. Conversely, the Administrator claimed to have instructed the former DON to report the incident to DPH and inform the police, but the former DON did not complete the necessary investigation or reporting. This miscommunication and failure to adhere to the facility's policy resulted in the delayed reporting of the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The Facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who was found with a bump on their left forehead. The incident occurred on 01/02/25, but the Facility did not provide documentation to support that an investigation was initiated immediately. The Facility's policy requires that injuries of unknown etiology be investigated by interviewing individuals who may have knowledge of the event, reviewing medical records, and examining staffing schedules. However, the investigation was incomplete as it lacked a witness statement or interview with the Physical Therapy Aide (PTA) who discovered the bump. The resident involved had a history of bilateral pulmonary embolisms, deep vein thrombosis, low back pain, and dementia, and was admitted to the Facility in December 2024. Despite the Administrator instructing the former Director of Nurses (DON) to report the incident to the Department of Public Health and inform the police, the former DON did not follow through with the investigation. The Facility's Health Care Facility Reporting System report, dated 02/02/25, classified the incident as an injury of unknown origin but lacked evidence of a timely and comprehensive investigation.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that the care plans for two residents, who were identified as at risk for falls, were reviewed and revised after they experienced falls. Resident #1, admitted in December 2024 with diagnoses including bilateral pulmonary embolisms, deep vein thrombosis, low back pain, and dementia, had a care plan that included interventions to prevent falls. However, after an unwitnessed fall on December 29, 2024, where the resident was found sitting on the floor, the care plan was not updated to address this new behavior. Nurse #2, during an interview, admitted to not knowing who was responsible for updating care plans and confirmed that no changes were made to Resident #1's care plan following the incident. Similarly, Resident #2, admitted in November 2024 with diagnoses including anxiety, deep vein thrombosis, hypertension, and dementia, experienced an unwitnessed fall on November 27, 2024. Despite this incident, no new interventions were added to the resident's care plan. The MDS Coordinator stated that floor nurses or supervisors were responsible for updating care plans after the initial comprehensive care plans were completed. The acting DON was unaware that the care plans for both residents had not been updated following their fall incidents, despite the facility's policy requiring review and revision of care plans after such events.
Failure to Employ Full-Time Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility failed to employ a full-time Social Worker as required for facilities with more than 120 beds. During the entrance conference, the Administrator and Regional Nurse confirmed that there had been no full-time Social Worker since July 2024. The facility, with a licensed bed capacity of 170 and 162 active beds, had been utilizing consulting Social Workers who provided limited hours of coverage each week, which did not meet the full-time requirement. The Administrator acknowledged that a job posting for a full-time Social Worker had been active since July 2024, but the position remained unfilled. Consulting Social Worker hours varied significantly, with some weeks having no coverage at all. As of late October 2024, the facility arranged for a consulting Social Worker to provide 24 hours of coverage per week, but this still fell short of the full-time requirement. The deficiency was identified through interviews and record reviews, highlighting the facility's ongoing struggle to secure adequate social work services for its residents.
Failure to Maintain Court-Approved Treatment Plans for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that court-approved treatment plans for the administration of antipsychotic medications were active and current for two residents, both of whom had severe cognitive impairments and legal guardians. Resident #16, diagnosed with paranoid schizophrenia and dementia, had a treatment plan that expired, yet continued to receive Risperidone as per physician's orders. Similarly, Resident #25, also diagnosed with paranoid schizophrenia, had an expired treatment plan but continued to receive Risperidone and Olanzapine. Both residents were deemed incapable of self-care due to mental illness, and their guardianships were appointed by the Commonwealth of Massachusetts Probate and Family Court. The facility identified an additional 21 residents with legal guardians who were being administered antipsychotic medication and required treatment plans. However, 19 of these residents did not have valid, court-approved treatment plans. The facility's administrator was unaware of the status of these treatment plans and attributed the responsibility to a social worker, who was not full-time and did not track guardianship issues. Despite the administrator's efforts to provide documentation, the survey team did not receive evidence of valid treatment plans for the 21 residents by the end of the survey.
Failure to Maintain Appropriate Temperature on North Two Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the North Two unit, where the temperature was not kept within the required range of 71-81 degrees Fahrenheit. Observations and interviews revealed that the unit was noticeably colder than the rest of the facility, with temperatures recorded as low as 58 degrees Fahrenheit. Multiple residents expressed discomfort due to the cold, with some wearing additional layers of clothing to stay warm. The issue was reported to staff over the weekend, but no corrective action was taken until the surveyor's visit. The Regional Facility Engineer acknowledged the temperature issue, noting a thermostat reading of 67 degrees Fahrenheit, while the Director of Nurses confirmed a reading of 62 degrees Fahrenheit. Despite the Administrator's claim that the heat had been fixed, subsequent observations showed the temperature remained below the acceptable range. The Administrator later stated that the Regional Facility Engineer was testing temperatures from the baseboard heat, but could not provide details on the measurement methods used. The deficiency highlights a failure to ensure a comfortable environment for residents on the North Two unit.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services to three residents, resulting in unsanitary conditions of respiratory equipment. Resident #51, who was admitted with complete C1-C4 quadriplegia and chronic respiratory failure, had oxygen tubing and nebulizer equipment improperly stored and undated. The oxygen tubing was found on the ground, and the nebulizer mask and tubing were left open to air, not stored in a plastic bag. Resident #51 was unsure of the last time the equipment was changed. Resident #31, admitted with chronic respiratory failure, asthma, and COPD, was observed using a nasal cannula with visible discoloration and outdated tubing. The nebulizer mask and BiPAP mask were improperly stored, with the BiPAP mask found in a cardboard box. Resident #31 reported that the equipment was changed every two weeks, but could not recall the last cleaning or change. The facility's failure to adhere to proper storage and maintenance protocols was evident. Resident #17, with chronic respiratory failure and obstructive sleep apnea, had a nebulizer and CPAP mask/tubing improperly stored and undated. The nebulizer mask was found on the floor, and the resident was unsure of the last equipment change. Interviews with nursing staff and supervisors confirmed that respiratory equipment was not stored or changed according to facility protocols, contributing to the deficiency in providing safe respiratory care.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a self-reported history of trauma. The resident, admitted in October 2021, had diagnoses including major depression, anxiety, and psychotic disorder. Despite comprehensive social service evaluations conducted on multiple occasions, which identified the resident's exposure to various traumatic events, the facility did not develop a care plan with individualized interventions to prevent potential re-traumatization. The evaluations noted the resident had witnessed events such as assault with a weapon, sexual assault, combat, captivity, life-threatening illness, severe human suffering, sudden or violent death, unexpected death of someone close, serious injury caused to someone, discrimination based on gender identity, and bullying. The consultant social worker, who assisted with resident evaluations, acknowledged that a trauma care plan should have been developed for the resident based on the evaluations. However, the facility had not employed a full-time social worker for several months, which contributed to the oversight. The consultant social worker did not participate in the care planning process, and the absence of a trauma-informed care plan was confirmed during interviews with the consultant social worker and the facility administrator.
Failure to Secure Treatment Carts
Penalty
Summary
The facility failed to ensure that treatment carts containing drugs and biologicals were locked when not under the direct supervision of a licensed nurse. This deficiency was observed across three units within the facility. The facility's policy, dated September 2018, mandates that medication rooms, carts, and supplies must be locked when unattended by authorized personnel. However, multiple observations by the surveyor revealed that treatment carts were left unlocked and unattended at various times and locations, including the North 1 Unit, South 2 Unit, and North 2 Unit. Interviews with several nurses confirmed the expectation that treatment carts should be locked when not in use and not in direct view of the nurse. Nurse #4, Nurse #8, Nurse #9, and Nurse #10 all acknowledged the importance of securing treatment carts to ensure safety. The Regional Clinical Nurse also reiterated that treatment carts should be locked and secured when not in use. Despite these acknowledgments, the facility did not adhere to its policy, resulting in the observed deficiency.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. The deficiency was identified during an observation of the main kitchen's walk-in refrigerator, where several food items were found improperly labeled or not labeled at all. These items included pasta salad, peeled cucumber, breakfast sausage, chicken tenders, gravy, cooked rice, hot dogs, and cubed cheese. Some of these items were past their use-by or expiration dates, while others lacked any date marking, contrary to the facility's policy and the FDA Food Code requirements. The facility's policy on food and supply storage, last revised in June 2018, mandates that food products be labeled with their contents and use-by dates, especially when opened, transferred to another container, or prepared at the facility. The policy also requires adherence to manufacturer recommendations for storage time and location. The FDA Food Code 2022 further specifies that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with a date by which it should be consumed, sold, or discarded. Interviews with the Food Service Director (FSD) and the Regional FSD confirmed that the observed practices did not meet the expected standards. The FSD acknowledged that the improperly labeled or unlabeled food items should have been disposed of, and the Regional FSD emphasized that food should always be labeled with an open/prepared date and a use-by date, and discarded if it exceeds these dates. The failure to properly label and date food products in the main kitchen represents a significant lapse in maintaining food safety and sanitation standards.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by professional standards. For two residents, physician and nurse practitioner visit notes were not uploaded into the medical records in a timely manner. Despite the physician and physician assistant having seen these residents regularly, their notes were not available in the medical records due to a delay in uploading by the medical records clerk, who cited a lack of training and a system glitch as reasons for the oversight. Additionally, the facility did not ensure accurate documentation of suprapubic catheter sizes for two residents. The medical records contained conflicting information regarding the catheter sizes, which were not updated after the residents returned from urologist appointments. This discrepancy was noted during interviews with nursing staff, who acknowledged the importance of having accurate catheter size information in case of replacement needs. Furthermore, the facility failed to include substance abuse assessments and notes in the medical records for residents diagnosed with alcohol or substance abuse. Although a Licensed Alcohol and Drug Counselor conducted assessments and developed care plans for these residents, the documentation was not incorporated into the medical records. The administrator and other staff were unable to locate the counselor's notes, which were supposed to be part of the residents' medical records, leading to incomplete documentation for these residents.
Inadequate Infection Control and PPE Use in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in their surveillance and data analysis processes. The Infection Preventionist (IP) did not interpret or evaluate the collected surveillance data on an ongoing basis, relying instead on a quarterly look-back evaluation by an external lab. This lack of real-time analysis meant that the facility was unable to identify trends or fluctuations in infection rates, types, organisms, or sites of infection. Additionally, the surveillance sheets for several months contained inaccuracies and incomplete data, such as miscategorizing illnesses and failing to document necessary signs and symptoms according to McGeer criteria. The facility also failed to ensure that staff used appropriate personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP) when providing care to residents with indwelling medical devices. For instance, a nurse was observed administering medications via a gastric tube to a resident without wearing a gown, despite the resident being on EBP. Similarly, a certified nursing assistant and a nurse failed to don gowns while performing catheter care and transferring a resident with a urinary catheter, both of which are considered high-contact care activities requiring EBP. Furthermore, a resident with a central venous catheter and a history of methicillin-resistant Staphylococcus aureus (MRSA) infection was not provided with the necessary PPE precautions. A nurse entered the resident's room without wearing gloves or a gown and failed to perform hand hygiene before and after the visit, despite a contact precaution sign on the door. These lapses in infection control practices highlight significant gaps in the facility's adherence to established guidelines and protocols for preventing the transmission of infections.
Failure to Notify Physician and HCP of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician and/or responsible party of changes in condition for two residents, leading to deficiencies in care. For one resident, the facility did not inform the physician of the dietitian's recommendation to change the nutritional formula to enhance caloric intake for a malnourished resident. Despite the dietitian's assessment indicating the need for a formula change to Glucerna 1.5 to address the resident's low BMI and inadequate nutritional intake, the physician was not made aware of this recommendation, and no change was implemented. Interviews with the nursing supervisor and the physician confirmed that the recommendation was not communicated, which should have been addressed following the dietitian's evaluation. For another resident, the facility failed to notify the Health Care Proxy (HCP) when the resident developed a deep tissue injury to the left heel and a stage 3 pressure wound to the left buttock. The nursing progress notes indicated the presence of these injuries and the involvement of a wound physician, but there was no documentation that the HCP was informed. The HCP later confirmed in an interview that they were unaware of the resident's injuries and the ongoing wound care, highlighting a lack of communication from the facility. These deficiencies indicate a failure to adhere to the facility's policy on communicating changes in a resident's condition to the appropriate parties. The policy requires professional staff to notify physicians, residents, and family members of significant changes, which did not occur in these cases, leading to a lapse in care coordination and oversight.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents, addressing their specific physical and functional needs. For one resident, who was admitted with diagnoses including low back pain and muscle wasting, the facility did not create a comprehensive care plan for chronic pain management. Despite the resident being cognitively intact and receiving both scheduled and PRN pain medications, there was no specific care plan addressing pain management. Interviews with the Nursing Supervisor and Regional Nurse confirmed the absence of a care plan related to pain management, which should have been developed upon the resident's admission. Another resident, admitted with conditions such as non-traumatic intracerebral hemorrhage and left arm contracture, also lacked a care plan for managing the contracture of the left upper extremity. The resident had been receiving occupational therapy, which recommended the use of a palm guard and elbow wedge to prevent skin breakdown and improve hygiene. However, there was no care plan developed to address these needs since the resident's admission. Interviews with the Director of Rehabilitation and the Director of Nurses confirmed the absence of a care plan for contracture management, which was necessary for the resident's care.
Failure to Maintain Professional Standards for Central Venous Catheter Care
Penalty
Summary
The facility failed to meet professional standards of care for a resident with a central venous catheter (CVC) tunneled into the right jugular vein for medication infusions. The resident, who was admitted with diagnoses including Staphylococcal arthritis, MRSA infection, and chronic renal disease, required specific care for the CVC, including flushing between medication infusions and changing needleless connectors and components. However, the facility did not have proper orders in place for these procedures upon the resident's admission, and there was no documentation indicating that these essential care tasks were performed. The deficiency was identified through a review of the resident's medical records, which showed a lack of orders for the care and maintenance of the CVC, including flushing and changing connectors. The facility's comprehensive care plans and Medication/Treatment Administration Records (MAR/TAR) from the resident's admission date failed to document the necessary catheter flushes and changes. It was only 12 to 14 days after admission that batch orders were entered for central line care, but these orders did not populate to the MAR/TAR, and there was no evidence that they were implemented. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the dressing changes for the CVC were done at dialysis, and the DON acknowledged that other physician's orders should have been implemented. The Nursing Supervisor could not explain the absence of initial orders and was unable to provide evidence of their implementation. This lack of adherence to professional standards of care for the resident's CVC represents a significant deficiency in the facility's care practices.
Failure to Implement Contracture Management for Resident
Penalty
Summary
The facility failed to monitor and document the range of motion (ROM) for a resident admitted with left arm contractures and did not implement recommendations from occupational therapy assessments for contracture management. The resident, who was admitted with severe cognitive impairment and multiple diagnoses including hemiplegia affecting the left side, did not have ROM measurements documented for the left upper extremity since admission. Despite recommendations for the use of a palm guard and elbow wedge, there were no physician's orders for these devices, and staff were not educated on their proper application. Observations revealed that the resident's positioning devices, such as the foam carrot and elbow wedge, were not used correctly. The foam carrot was often found on the overbed table or windowsill instead of in the resident's hand, and the elbow wedge was placed incorrectly between the elbow and side rail rather than in the elbow crease. Interviews with staff indicated a lack of awareness and training regarding the use of these devices, with some staff unaware of the need for these positioning aids due to the absence of physician's orders in the resident's treatment records. The Director of Rehabilitation and other staff acknowledged the lack of documentation and follow-up on the occupational therapy recommendations. The Director of Nurses and Regional Clinical Nurse confirmed that there was no policy for contracture management, and the nursing staff did not obtain physician's orders for the recommended positioning devices. The resident indicated through gestures that they were unaware of the correct placement of the devices, and attempts to use them were unsuccessful due to the contractures, which the resident felt had worsened since admission.
Unsafe Storage of Hazardous Items and Medications
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards on the South 2 Unit, where 29 out of 34 residents had Alzheimer's disease or dementia. Hazardous items, including a yellow bucket containing metal scrappers, a box of nails, a metal trowel, loose screws, and a one-gallon bucket of vinyl composition tile adhesive, were left unattended in the hallway. These items were accessible to residents, posing a safety risk. Staff, including Nurse #8 and the Regional Director of Maintenance, acknowledged the safety hazard, noting that the maintenance department was responsible for leaving the items out. Additionally, the facility failed to secure medications and diabetic testing supplies for a resident with diabetes mellitus, dementia, and a psychotic disorder. The resident's bedside dresser contained nail clippers, a bottle of glipizide, two bottles of metformin, insulin pens, a glucometer, test strips, and a lancet pen, all without a self-administration assessment or physician's order. The resident's room was left open and accessible to wandering residents, with no staff supervision in the vicinity. Nurse #8 confirmed that the resident did not self-administer medications and that these items should not have been in the room, highlighting a significant safety hazard.
Inadequate Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling suprapubic catheter for a resident. The resident, who was cognitively intact and had a history of neuromuscular dysfunction of the bladder and hydronephrosis, was observed with a urinary catheter drainage bag resting on the floor without a protective barrier, contrary to CDC guidelines and physician's orders. The drainage bag was also not stored inside a privacy bag as required. During observations, the drainage bag was seen leaking urine onto the floor, and the nurse acknowledged that the bag should not have been on the floor due to infection control reasons. The Director of Nursing confirmed that the resident's care plan did not address the issue of the drainage bag being placed on the floor, which was a lapse in maintaining sanitary conditions for the catheter device.
Failure to Issue Transfer/Discharge Notices
Penalty
Summary
The facility failed to issue a Notice of Transfer/Discharge to two residents, both of whom had severe cognitive impairments and legal guardians, when they were emergently transferred to the hospital. Resident #16, who had diagnoses including diabetes mellitus type 2, anxiety, and dementia, was transferred to the hospital on two occasions after pulling out a Peripherally Inserted Central Catheter (PICC) line. Despite these transfers, there was no documentation indicating that a Notice of Transfer/Discharge was provided to the resident, their representative, or the ombudsman. Similarly, Resident #25, diagnosed with chronic obstructive pulmonary disease and unsteadiness on feet, was transferred to the hospital twice due to difficulty breathing and a fall. The facility's records did not show that a Notice of Transfer/Discharge was issued to the resident, their representative, or the ombudsman for these transfers. Interviews with facility staff confirmed the absence of these notices in the residents' medical records.
Failure to Issue Bed Hold Policy Notices
Penalty
Summary
The facility failed to issue Bed Hold Policy Notices to two residents upon their transfer to the hospital, as required by their own policy. The policy, last revised in May 2018, mandates that residents or their representatives be informed in writing about the bed hold and return policy prior to any transfers or therapeutic leaves. This includes details about the rights and limitations regarding bed-holds, the reserve bed payment policy, and the facility's per diem rate for holding a bed. However, upon review, it was found that the facility did not provide these notices to two residents who were transferred to the hospital. The first resident, admitted in May 2014, had severe cognitive impairment and a legal guardian. This resident was transferred to the hospital on two occasions, once after pulling out a PICC line and another time for the same reason, yet no Bed Hold Policy Notices were issued. The second resident, admitted in May 2019, also had severe cognitive impairment and a legal guardian. This resident was transferred to the hospital due to difficulty breathing and after being found on the floor, but again, no Bed Hold Policy Notices were issued. Interviews with nursing staff confirmed the absence of these notices in the residents' medical records.
Failure to Supervise Resident During Smoke Break Leading to Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of traumatic brain injury, paranoid schizophrenia, and substance use disorder, who required supervision while smoking. During a scheduled supervised smoke break, the Nurse Supervisor allowed another resident, who could smoke independently, to exit the facility. Unbeknownst to the Nurse Supervisor, the resident requiring supervision and another resident also exited the facility. The resident requiring supervision eloped from the facility and was not noticed missing until the smoke break ended, approximately fifteen minutes later. The resident's whereabouts were unknown for nine days until they checked into a hospital emergency department 13 miles away from the facility. The facility's policies on elopement and smoking supervision were not adequately followed. The elopement policy required staff to promptly report and attempt to prevent any resident from leaving the premises. The smoking policy required residents needing supervision to be monitored by a staff member during smoking times. However, the Nurse Supervisor did not ensure continuous supervision in the smoking area or the facility lobby during the smoke break, leading to the resident's elopement. The resident's medical records indicated severe cognitive impairment, limited attention, impaired judgment, and a court-appointed legal guardian. Despite these factors, the facility's elopement risk assessments were inconsistent, and no care plan was developed to address the resident's elopement risk. The Nurse Supervisor's failure to verify the resident's presence during the smoke break and the lack of a proper elopement care plan contributed to the resident's elopement and subsequent nine-day absence from the facility.
Removal Plan
- The Facility developed a new Smoking Supervision Plan which included two staff members would be assigned, ensuring the safety of smokers during every smoking break time, one staff member would be physically, continuously present outside in the smoking area supervising smokers/dispersing cigarettes and a second staff member would continuously be present in the Facility lobby supervising the reception area and residents, staff and visitors as they egress through the locked front door.
- The Facility developed and implemented a Supervised Smoking Form for the smoking supervisor to document which residents attended the smoking break time, the return of smoking materials to the staff member supervising smoking break and the return of all residents inside of the Facility after the smoking break time was over.
- Administrative and Clinical Management reviewed the facility Elopement Policy and Risk Evaluation Form for purpose of revision. The Assistant Director of Nursing (ADON) provided education to licensed nursing staff regarding completion of the Elopement Risk Assessments, accuracy and evaluation of the assessment, identifying triggers for risk of elopement, and residents with SUD and/or Psychosis must be considered at risk for and care planned for elopement.
- The Director of Nursing initiated a change to the daily Staffing Schedule to assign particular nursing staff members for transport of residents who smoke from North 2 (the secure unit) to the smoking area at the start of each smoking break time.
- The Director of Nursing and Administrator initiated a plan for a leadership staff member (Administrator, Manager of the Day, nursing supervisor) to assign specific staff members to supervise the reception area and for staff, resident, visitor egress through the locked front door during each Facility smoking break time.
- The Administrator, Director of Nursing and Assistant Director of Nurses trained all staff involved in the supervision of smokers (nursing, reception, activities) on the new Smoking Supervision Plan and the Supervised Smoking Form.
- The Administrator and/or Director of Nursing and/or their designee initiated interviews of staff members to determine their understanding and compliance of the new Smoking Supervision Plan.
- The Administrator and/or Director of Nursing and/or their designee initiated that observations to be conducted by administrative staff during the resident smoking break time, for compliance.
- The Director of Nursing and/or Administrator and/or their designee initiated administrative staff review of the Supervised Smoking Forms.
- The Administrator and/or Designee reviewed the corrective actions plans in an ad hoc QAPI meeting, and will continue to review for compliance, at QAPI to ensure compliance.
- The Administrator and/or Designee are responsible for overall compliance.
Failure to Implement Smoking Safety and Elopement Risk Care Plans
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions from a resident's Plan of Care related to smoking safety. The resident, who had a history of traumatic brain injury, paranoid schizophrenia, and substance use disorders, was supposed to be supervised by staff while smoking. However, video surveillance footage showed that the resident was outside smoking for almost a full minute without supervision before the assigned staff member arrived to supervise the smoking area. This lapse in supervision occurred because the Nurse Supervisor, who was responsible for supervising the smoking break, allowed the resident to exit the facility without realizing it due to a limited view from the reception desk. Additionally, the facility failed to accurately assess the resident's risk of elopement based on criteria identified on the facility's elopement risk form. Despite the resident having a history of substance abuse and psychosis, which should have flagged them as at risk for elopement, the assessments were inconsistent. Some assessments indicated the resident was at risk, while others did not, and no care plan was developed to address this risk. The MDS Nurse confirmed that no elopement care plan was created at any time during the resident's stay. Interviews with the Regional Director of Clinical Operations, the Director of Nursing, and the Administrator revealed that they were unaware of the specific criteria on the elopement risk form that required a care plan for residents with a history of substance abuse or psychosis. They disagreed with the wording on the assessment form and did not believe it was appropriate to determine elopement risk based on diagnosis alone. This lack of awareness and disagreement with the assessment criteria contributed to the failure to develop an appropriate care plan for the resident's elopement risk.
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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