Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norwood Healthcare during CMS and state inspections, most recent first.
Failure to obtain ordered STAT x-ray for a resident with dementia and a recent fall led to delayed imaging of a painful, bruised right arm. Nursing documented acute pain, bruising, and guarding, and a STAT x-ray was ordered and confirmed, but the x-ray provider did not come to the facility and staff did not follow up during the shift or after report. The next day, the resident was sent to the ED, where imaging showed a closed fracture of the right distal radius.
Failure to Maintain Elopement Risk Care Plan: A resident with severe cognitive impairment, exit-seeking behavior, and a high elopement risk score had a wandering/elopement care plan resolved without IDT review or a new risk reassessment. The resident later eloped after being observed near the elevator and leaving with an unknown person; staff did not realize the resident was missing until hours later, and police found the resident at South Station and transported the resident to the hospital.
Elopement Risk Not Maintained or Implemented: A resident with dementia, severe cognitive impairment, wandering, and a high elopement score did not have a current elopement/wanderer care plan, was not listed in the elopement binder/photo alert system, and was able to exit through the main door after being mistaken for a visitor. Staff did not realize the resident was missing until hours later, and police later found the resident at a train station and transported him/her to the hospital.
The facility failed to maintain a QAPI program with documented development, implementation, and evaluation of corrective actions or performance improvement activities, and it did not address the full range of care and services, including clinical care. The QAPI binder contained no documented projects or PIPs, only quarterly sign-in sheets, lab/pharmacy reports, and kitchen audits without a stated project or goal. The Administrator, DON, and ADON all reported that only a new pressure ulcer project existed and that other work, such as psych consent audits, was being done outside of a formal QAPI format.
The facility failed to maintain a QAPI program with documentation of corrective actions or performance improvement activities. Review of the QAPI policy showed the committee was responsible for reviewing data, maintaining minutes and project records, and monitoring whether interventions were effective, but the 2025 QAPI binder had no documented projects/PIPs and no evidence of data collection or analysis. The Administrator stated he had no data to provide, could not speak to what had been done during the prior year, and said the facility’s QAPI process had to change.
QAPI Committee Lacked Required Member Participation: The facility failed to maintain a QAPI Committee with the required members attending and participating in quarterly meetings. The policy required the Medical Director, Administrator, DON, IP, and two other staff members, but interviews and sign-in sheets showed the DON and ADON/IP were not consistently present, and staff stated there were no actual meetings or discussions of QAPI plans or projects despite signatures on attendance sheets.
Mandatory QAPI training was not provided to all staff on the facility’s current QAPI elements, projects, goals, and revisions. Records showed staff were trained only on the general QAPI concept, and Consulting Staff #3 stated she had no records of QAPI project education or training and that the online training she provided was only general policy and procedure education, not specific to facility projects.
Resident Council concerns were repeatedly raised but not documented with follow-up or facility responses in the minutes. Residents reported they were unsure of the grievance and follow-up process, and the Activity Director said she only handled issues verbally, had no way to track department head follow-up, and had never initiated a grievance form from a Resident Council complaint. The DON-level leader stated written responses and grievance follow-up were expected, but the record showed repeated concerns about activities, meals, and social events without documented resolution.
Failure to provide an accessible grievance process and retain grievance records: Residents reported they did not know where grievance forms were, who the grievance officer was, or how to file anonymously, and the grievance forms were kept behind the nurses’ station rather than being readily available. Surveyors also found no posted grievance information in the building, staff were unsure of the process, and the facility could not produce 3 years of resolved grievance records.
A resident with depression and dementia had a handwritten NP order to discontinue Trazodone 25 mg BID and start Trazodone 50 mg BID, but the order was not entered into the EMR or implemented. The MAR showed the resident continued receiving the lower dose, and a psych note stated the increase was delayed while staff waited for spouse approval even though the activated HCP was on file. Staff said handwritten orders were supposed to be flagged and transcribed, but the order was missed for nearly three months.
Failure to Arrange Vision Services: A cognitively intact resident with DM and worsening blurry vision signed consent for eye health services and repeatedly asked to see the eye doctor, but the resident was not seen for months. Records and staff interviews showed the DON coordinated optometry visits inconsistently, the resident was placed on a DNT list for insurance reasons, and no one followed up to resolve the missed vision services despite multiple provider visits to the facility.
Failure to Implement Antibiotic Stewardship Program: The facility did not carry out its antibiotic stewardship program or monitor antibiotic use as required by policy. The IP said she only documented antibiotics on surveillance sheets and did not follow up with providers, while the DON said he expected the IP to notify prescribers and document when criteria were not met. A resident with repeated UTI concerns was started on antibiotics, but the record lacked complete McGeer criteria, urine culture documentation, and clear provider rationale for continued antibiotic use, and one antibiotic start was not reflected on the surveillance sheets.
Resident Not Invited to Care Planning Meetings: A cognitively intact resident with COPD and emphysema said he or she was not invited to care conferences or IDT meetings to discuss the plan of care. Care plan notes did not document whether the resident or representative was invited or attended, and staff interviews showed confusion about who was responsible for sending invitations and coordinating the meetings.
PRN olanzapine remained active beyond the 14-day limit for a resident with depression, vascular dementia, and Alzheimer's dementia. The resident had severe cognitive impairment and was receiving antidepressant and antipsychotic medications, but the PRN antipsychotic order stayed in place for 57 days and was administered four times after the initial 14 days without documented provider review or extension at each interval. Staff and the DON confirmed the order should have been limited to 14 days.
MRR recommendations were not timely addressed for a resident receiving weekly Vitamin D. The consultant pharmacist recommended checking a Vitamin D level to see if the dose could be reduced, but nursing did not transcribe or complete the lab order when the physician signed it, and the recommendation had to be reissued. The DON and nursing staff stated they did not have a reliable process to ensure pharmacy recommendations were followed through.
Kitchenette Floors Not Maintained in Sanitary Condition: Surveyors observed four unit kitchenettes with missing floor tile, receding grout, debris buildup, food items and other items stored behind or between refrigerators and walls, and mouse droppings. The FSD, DCO, and HM stated kitchenette floors were expected to be kept clean and sanitary, with no missing tiles, debris buildup, or mouse droppings.
A resident with severe cognitive impairment and an invoked HCP was transferred to the hospital multiple times, but the facility did not document providing the HCP with the required transfer/discharge notices and bed hold policy for several of those transfers. One transfer also lacked a completed discharge/transfer evaluation, and staff stated the notices should have been given and documented each time the resident went out to the hospital.
A resident with obesity, dysphagia, and a history of pneumonitis from inhalation of food and vomit remained on a puree diet even after the SLP documented an upgrade to minced and moist. The diet order was entered in the wrong category, the prior order was not discontinued, and the kitchen was not notified, so the resident continued receiving pureed meals instead of the ordered texture.
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 Ordered STAT X-ray for Resident With Arm Pain After Fall
Penalty
Summary
The facility failed to provide radiology services consistent with a physician’s order when a resident who had Alzheimer’s disease, dementia, lack of coordination, difficulty walking, and a history of falling developed acute pain and bruising in the right shoulder and arm after an unwitnessed fall. On the morning of 03/31/26, nursing documented visible quarter-size dark purple bruising to the right upper and lower arm, facial grimacing, and the resident saying “ouch” when the arm was touched. The physician ordered a STAT x-ray of the right shoulder and arm to rule out fracture, and the radiology provider confirmed the STAT order at 11:52 A.M. Nurse #2 stated she called the x-ray provider after obtaining the STAT order, but the provider did not come to the facility during her double shift, which ended at 11:00 P.M., more than 11 hours later. She acknowledged she did not call the x-ray provider back at any time during her shift to follow up on when the x-ray would be completed. She also told the oncoming night-shift nurse that the x-ray had not yet been done and needed follow-up. Nurse #5 stated she was informed during shift report that the STAT x-ray was still pending, but she did not call the x-ray provider to check on the status. The next morning, Nurse #3 informed the ADON that the x-ray provider still had not come to complete the STAT x-ray. Nurse #3 then contacted the physician and obtained an order to send the resident to the hospital ED for imaging. The medical record contained no documentation that nursing followed up with the x-ray provider after the order was placed. The hospital discharge summary showed the x-ray revealed a closed fracture of the right distal radius.
Failure to Maintain Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop, maintain, and implement an active, interdisciplinary, person-centered care plan for a resident with a known elopement risk. The resident was admitted in November 2025 with diagnoses including dementia, insulin-dependent type 2 diabetes, restlessness, and agitation. Records showed severe cognitive impairment on the MDS with a BIMS score of 3, disorganized thinking, and a need for supervision while walking. Hospital records before admission documented wandering, entering closets at night, increasing aggressive and wandering behaviors, inability to be left alone without supervision, and a need for a secure unit due to potential to wander. On admission, nursing documentation described the resident as exit-seeking, oblivious to needs or safety, watching others go out of doors, and having an elopement attempt in the prior 30 days. An elopement risk assessment identified the resident as high risk with a score of 14. The resident’s care plan included wandering/elopement interventions such as diversions, identifying wandering patterns, monitoring triggers, and a wander alert device specification, but the active care plan did not contain a wandering or elopement plan. The existing wandering/elopement care plan was resolved on 11/28/25 without IDT review or a subsequent risk reassessment, despite ongoing physician notes that the resident wanted to go home and a psychiatric evaluation noting confusion, impaired judgment, and impaired memory. On 1/17/26, the resident eloped from the facility after being observed wandering near the elevator for 20 to 30 minutes, entering the elevator with an unknown person, and exiting the front door. Staff did not identify the resident as missing until about 5:00 PM. Police later located the resident’s cell phone signal and found the resident at Boston’s South Station, approximately 21 miles away, and transported the resident to the hospital. During interviews, the MDS nurse stated she resolved the elopement/wandering care plan based on the MDS lookback period and did not recall meeting with the resident, while the DON and consulting staff stated that elopement risk care planning should not have been resolved by the MDS nurse alone and required IDT review.
Elopement Risk Not Maintained or Implemented
Penalty
Summary
The facility failed to ensure adequate supervision and elopement prevention for a resident with dementia, wandering behavior, and a high elopement risk score. The resident was admitted with diagnoses including dementia, insulin-dependent type 2 diabetes, restlessness, and agitation. The record showed severe cognitive impairment on the MDS, disorganized thinking, supervision needed while walking, and hospital documentation stating the resident wandered, could not be left alone without supervision, and needed a secure unit. The resident’s admission nursing evaluation documented exit-seeking behavior, obliviousness to safety needs, and an elopement attempt within the prior 30 days, and an elopement risk assessment rated the resident at high risk with a score of 14. Despite those findings, the resident’s active care plan did not include a current wandering or elopement plan. The prior elopement/wanderer care plan had been active only from 11/18/25 to 11/28/25 and was resolved even though the resident continued to wander, including nursing notes on 12/9/25 and 1/9/26 and surveyor observations on 1/13/26 and 1/14/26 of the resident ambulating up and down the hallway with a cane. Staff interviews showed disagreement about the resident’s status: the MDS nurse said she resolved the plan because she did not see documentation of wandering, while consulting staff stated the plan should have remained in place until a subsequent assessment and interdisciplinary review determined the resident was no longer at risk. The resident was also not included in the elopement binder/photo alert system, and staff stated there was no evidence explaining why the elopement care plan had been discontinued. On 1/17/26, the resident eloped from the facility. Investigation records showed the resident had been wandering near the unit elevator for 20 to 30 minutes before leaving, asked another resident whether a visitor had left, entered the elevator with an unknown person, and exited through the front door. The administrator, who was at the front desk, saw a person at the door trying to exit, accepted the resident’s statement that he/she was a visitor, and unlocked the door because the resident was not in the elopement binder and was not recognized. Staff did not discover the resident missing until about 5:00 P.M., and police later located the resident at South Station in South Boston, approximately 21 miles away, and took the resident to the hospital. The resident’s son reported the resident had dementia, severe diabetes, wandering behavior, and had previously stated he/she would escape.
Lack of Documented QAPI Projects and Meeting Minutes
Penalty
Summary
The facility failed to maintain a QAPI program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities, and failed to maintain a QAPI program that addressed the full range of care and services, including clinical care. The facility policy titled Quality Assurance Performance Improvement (QAPI), last revised 6/2024, stated that the committee reviews and analyzes facility data, identifies areas for improvement, maintains QAPI minutes and PIPs, uses PDSA and RCA, and completes an annual self-assessment and evaluation of the program. Review of the 2025 QAPI binder with the Administrator showed no documented projects or PIPs worked on during the year, only sign-in sheets for quarterly meetings and lab/pharmacy reports, with no meeting minutes. Kitchen audits from July through October were present but did not identify a project or goal. During interviews, the Administrator stated there was one clinical project for pressure ulcers that had just started and he had no details, and he did not have any other QAPI information or documented projects from 2025. The ADON said the only PIP she had was a new pressure ulcer project and that they worked on things but not in a QAPI format. The DON said they had been working on psych consents for a few months, but there was no PIP for it and no projects in QAPI format from last year.
Lack of QAPI Documentation and Project Oversight
Penalty
Summary
The facility failed to maintain a QAPI program with documentation showing the development, implementation, and evaluation of corrective actions or performance improvement activities. Review of the facility’s QAPI policy, last revised 6/2024, stated that the QAPI Committee is responsible for reviewing and analyzing data, directing appropriate actions, maintaining QAPI minutes and project documentation, completing an annual self-assessment, and monitoring whether interventions are implemented and effective. The policy also stated that the Administrator is responsible and accountable for developing, leading, and monitoring the QAPI program. Review of the 2025 QAPI binder with the Administrator showed no documented projects or PIPs worked on during the year and no evidence of data collection or analysis. During interview on 1/20/26 at 3:00 P.M., the Administrator stated he did not have any data on any projects to provide, said there should be plans for each department to work on, but he did not have anything to speak to regarding what had been done last year, whether projects had been revised, or whether they were effective. He also stated he did not have anything related to the prior year’s plan of correction to discuss and said the way QAPI was being done had to change.
QAPI Committee Lacked Required Member Participation
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members attending and participating in its quarterly meetings. The facility policy stated the QAPI Committee was to meet quarterly and include the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members. Review of the quarterly sign-in sheets for 2025 showed the DON was present at the April meeting, when he also served as the IP, and that the DON and ADON/IP were present at the July and October meetings. During interviews, the ADON/IP stated she had not attended a QAPI meeting since being hired about six months earlier and said the IP should be part of the QAPI process. The Administrator stated he could not speak to the meetings or attendance because he had no meeting minutes and could only refer to the sign-in sheets, and he said he was not hired until November 2025. The ADON stated she was not employed at the facility for the April meeting and said the previous Administrator would write up QAPI and have her sign the attendance sheet, but that there were never any meetings to discuss QAPI plans or projects. The DON stated that although he had attended and participated in QAPI meetings in the past as an ADON, since becoming DON in 2025 he had never attended a QAPI meeting and said the previous Administrator just had staff sign the paper without any meetings or discussion of projects.
QAPI Training Not Provided to All Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to all staff to outline the current elements, projects, goals, and revisions of the program. Review of the facility’s QAPI policy, last revised 6/2024, indicated that communication about QAPI activities is shared via staff meetings and/or trainings. However, review of the facility’s education records showed staff were trained only on the general concept of QAPI and did not show education on the facility’s specific QAPI projects, plans, or goals as required. During an interview on 2/2/26 at 1:30 P.M., Consulting Staff #3 stated she did not have any records related to any QAPI project and education/training from 2025 and said the online training record she provided was only education on the general policy and procedure, not on any specific projects the facility was working on.
Resident Council Concerns Not Documented or Resolved
Penalty
Summary
The facility failed to ensure concerns brought forward from Resident Council were addressed and promptly resolved, and the residents were not provided documented facility responses to the group. The facility policy titled Resident Council stated that a designated staff person approved by the resident group and facility would assist and respond to written requests from group meetings, and that department heads must respond in writing to grievances addressed in the minutes before the next meeting. However, review of Resident Council minutes from 7/5/25, 8/7/25, 9/9/25, 10/9/25, 11/13/25, and 12/9/25 showed repeated resident concerns such as wanting a video game, more hamburgers, evening activities, going outside more, a Bingo evening activity with prizes, a specific exercise activity more than once a month, more soup and meal options, and a monthly social event with food, with no documented follow-up or facility response included in the minutes. During a resident group meeting on 1/15/26, 13 residents attended and reported that concerns were not being reviewed or followed up on; 7 of 13 said they only discuss the activities department at Resident Council, 4 of 13 said no one reviews the outcome of previously discussed concerns, and 5 of 13 were unsure of the grievance process or follow-up process for requests made from Resident Council. In an interview on 1/14/26, the Activity Director stated she verbally discusses issues with the appropriate department head, does not have a way to track follow-up from department heads, has never initiated a grievance form from a complaint at Resident Council, and was aware of the same topics being brought up multiple times with no follow-up indicated. The Director of Clinical Operations stated on 1/15/26 that she expected the staff facilitating Resident Council to address concerns across departments, initiate grievances when residents voice complaints or group concerns, obtain written follow-up from department heads, and report responses back to the Resident Council group.
Failure to Provide Accessible Grievance Process and Retain Grievance Records
Penalty
Summary
The facility failed to ensure residents had the right to voice and formulate grievances, have grievances responded to promptly, and receive a resolution. The facility’s grievance policy identified the administrator as the grievance official and stated that residents, representatives, family members, employees, or advocates could file grievances without fear of discrimination or reprisal. The policy also stated that staff would inform residents or their representatives of the grievance process, assist with filing a written grievance using the grievance form as needed, allow anonymous grievances to the extent possible, and maintain evidence of grievance results for three years. During a resident group meeting with 13 residents, 11 residents said they were not sure of the process for completing a grievance form, where the forms were located, or who the grievance officer was. Nine residents said they were not sure what would be considered a grievance or how to formulate a grievance anonymously. The surveyor toured the building and did not find information posted about the grievance process. An empty green folder labeled grievances was observed in the lobby, and the surveyor also did not find information on how to file a grievance, how to file anonymously, or who was responsible for the grievance process. Staff interviews confirmed grievance forms were kept behind the enclosed nurses’ station and were not accessible to residents or visitors without asking staff for help. Nurses and other staff were unsure of the grievance process, where forms were located, who the grievance officer was, and how anonymous grievances would be handled. The administrator stated he was the grievance officer and expected staff to assist residents, but he was not aware there was no process in place for anonymous filing. In addition, the facility could not provide three years of resolved grievance records and was unable to produce grievances before 1/2025; the grievance book provided only covered May 2025 through December 2025, and staff stated they expected grievance records to be retained for three years after resolution.
Failure to Transcribe and Implement Trazodone Order
Penalty
Summary
The facility failed to ensure that Resident #8 received care and treatment in accordance with professional standards when a physician's order to increase Trazodone was not transcribed into the electronic medical record and was not implemented. Resident #8 was admitted in June 2025 with diagnoses including depression, vascular dementia with behavioral disturbances, and Alzheimer's dementia. The MDS dated 12/19/25 indicated severe cognitive impairment, a BIMS score of 3 out of 15, depressed mood, and use of antidepressant and antipsychotic medications. The paper chart contained a handwritten order dated 11/18/25 from the NP to discontinue Trazodone 25 mg BID and start Trazodone 50 mg BID, but the active electronic orders still showed Trazodone 50 mg, 0.5 tablet by mouth two times daily, and the MAR showed the resident continued to receive Trazodone 25 mg BID through the date of review. A psychiatric progress note dated 11/25/25 stated the resident had a recommendation for an increase in Trazodone that was not initiated because staff were waiting for spouse approval, even though the resident's HCP had been activated on admission and the spouse was not the activated HCP on file. Staff interviews indicated handwritten orders were supposed to be flagged and entered into the computer, but no one knew why this order was missed for almost three months, and the DON stated there was no good system in place to ensure orders were not missed.
Failure to Arrange Vision Services
Penalty
Summary
The facility failed to ensure that necessary vision services were provided for one resident who was admitted with diagnoses including diabetes mellitus with neuropathy, ketoacidosis, foot ulcer, and hyperglycemia. The resident was cognitively intact with a BIMS score of 15 out of 15 and had signed a consent/request for eye health services. During interview, the resident reported worsening blurry vision, stated the left eye was worse than the right, and said the eye doctor had been promised but had not seen the resident for months despite repeated requests. The record showed a physician order for consults including optometry/ophthalmology, and a social service note documented the resident’s request to be seen by the eye doctor, with nursing made aware. However, progress notes did not show why the resident had not been seen, when an appointment would occur, or any follow-up related to the pending eye visit. Interviews with nursing and DON staff showed the DON coordinated vision services, but he was unsure when the eye doctor last came or when the next visit would be, could not retrieve related emails, and initially did not have the resident’s consent on file. The vision services provider’s visit log showed the resident had not been seen between August 2025 and January 2026, even though the provider had visited the facility nine times during that period. Staff later identified the resident on a Do Not Treat list for insurance reasons, and the DON and consulting staff acknowledged the resident should have been seen but was not, with no one having resolved the issue for months.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program, including antibiotic use protocols and monitoring of antibiotic use, as required by its policy and CDC guidance. The facility policy stated that the program was intended to optimize antibiotic prescribing, monitoring, and communication of resident changes in condition, and that the Infection Preventionist (IP) was to review antibiotic utilization, track antibiotic starts, and report antibiotic use patterns and negative outcomes. During interview, the IP stated she only documented antibiotic information on surveillance sheets, did not follow up with providers when antibiotics were prescribed, and did not maintain the antibiotic stewardship program. The DON stated he expected the IP to inform prescribers and document when a resident did not meet antibiotic usage criteria, and said he was not aware the program was not being implemented. Resident #58 had multiple concerns for UTI and was placed on antibiotics, including Vantin and later Macrobid, but the record did not show the required McGeer Criteria for Infection being completed for each antibiotic start. The McGeer documentation dated 12/17/25 included suprapubic pain and new or marked increase in urgency and frequency, but did not include microbiologic criteria such as urine culture results. The medical record also lacked further McGeer criteria documentation, and progress notes did not document a reason for continued antibiotic use. Notes indicated an antibiotic was started after a recent hospitalization without a documented urine culture, and later the resident was placed on Macrobid for UTI, but physician and nurse practitioner notes did not provide reasoning for continued antibiotic therapy. The December 2025 surveillance sheets also failed to reflect one of the antibiotic starts.
Resident Not Invited to Care Planning Meetings
Penalty
Summary
The facility failed to ensure that Resident #24 was invited to participate in his or her person-centered care planning meetings. The resident was admitted in November 2025 with diagnoses including chronic obstructive pulmonary disease and emphysema, and the MDS assessment dated 10/24/25 showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. During an interview on 1/13/26, Resident #24 stated that he or she had not been invited to any care conferences or interdisciplinary team meetings to discuss the plan of care. Review of the resident’s care plan meeting notes dated 11/12/25 and 8/19/25 showed no documentation of whether the resident or representative was invited, whether they attended or did not attend, or which staff members were present. Staff interviews showed confusion about who was responsible for the invitation process: the Activities Director said she had not attended care plan meetings since the previous social worker left, Social Worker #2 was unsure of the process, Social Worker #1 said she mailed invitations to responsible parties and assumed the receptionist delivered invitations to residents who were their own responsible person, the MDS Coordinator was unsure how residents were invited, and the Receptionist said social workers were responsible for inviting residents who were their own responsible person. The Director of Clinical Operations stated she expected residents to be invited and that a process should be in place to ensure resident participation.
PRN Antipsychotic Order Remained Active Beyond 14 Days
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use by allowing a PRN order for olanzapine (Zyprexa) to remain active beyond the 14-day limit. The resident was admitted in June 2025 with diagnoses including depression, vascular dementia with behavioral disturbances, and Alzheimer's dementia. The MDS assessment dated 12/19/25 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and documented that the resident was feeling down and depressed and was receiving antidepressant and antipsychotic medications. The physician's order for olanzapine 5 mg orally disintegrating tablet, given every 12 hours PRN for agitation or hallucinations, started on 6/18/25 and was not discontinued until 8/13/25. Review of the MAR showed the PRN antipsychotic order was active for 57 days and the resident received the medication four times after the initial 14 days. The record did not show provider evaluation or documentation extending the PRN order at each 14-day interval, and interviews with nursing staff and the DON confirmed that PRN antipsychotic orders should be limited to 14 days and that this order was not.
MRR Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews were addressed and implemented in a timely manner for one resident. The resident was admitted in October 2021 with diagnoses including osteoporosis, nutritional deficiency, and disorder of bone density. The consultant pharmacist noted that the resident had been receiving Vitamin D 50,000 units once weekly since 2023, described this as typically a loading dose that could be tapered down, and recommended evaluating a Vitamin D level to determine whether the frequency could be reduced to once or twice monthly. The physician signed the July recommendation and ordered a Vitamin D level, but the medical record did not show that nursing transcribed the order or scheduled the lab draw. When the recommendation was reissued in August, it was marked as unable to locate response and unsigned by the physician, and the record still did not show that the lab order had been transcribed or completed before the recommendation was repeated. The lab order was not written until after the recommendation was reissued, and the Vitamin D level was then drawn and resulted, followed by a later physician change to the Vitamin D order. During interviews, the DON said he printed the recommendations, the nursing supervisor completed them, and he did not oversee the process or know why the July order was not transcribed; he also said he had no process to ensure recommendations were followed up. Consulting staff and a nurse similarly stated there was no process in place to ensure completion and that they did not know why the order was not written in July.
Kitchenette Floors Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. On 1/14/26, the surveyor observed four unit kitchenettes that were not maintained in a clean, sanitary condition, including a North 2 Unit corner floor area with a TV mount, box, and bag of clothes with a sizeable amount of mouse droppings underneath, peanut butter crackers and condiment packets between the refrigerator and wall, and a South 2 Unit kitchenette with a missing floor tile at the floor/wall junction containing buildup of crumbs and debris. Additional observations included a North 1 Unit kitchenette with receded grout at the floor/wall junction collecting debris, crumbs, and buildup, a missing floor tile, and items such as a water bottle, condiment packets, paper towels, and cups stored behind or between the refrigerator and wall. In the South 1 Unit kitchenette, the surveyor observed a package of peanut butter crackers, condiment packets, broken tile pieces, debris behind the refrigerator, broken tile around the perimeter of the floor/wall junction, receding grout with debris buildup, and mouse droppings. The Corporate FSD, DCO, and HM each stated that kitchenette floors were expected to be kept clean and sanitary, with no missing tiles, receding grout, debris buildup, or mouse droppings.
Failure to Provide Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge documentation and bed hold notices to the responsible person/invoked Health Care Proxy for Resident #8 during five hospital transfers. Resident #8 was admitted in June 2025 with diagnoses including depression, vascular dementia with behavioral disturbances, and Alzheimer's dementia, and had severe cognitive impairment with a BIMS score of 3 out of 15. The resident's HCP was invoked on 6/17/25. Review of the medical record showed transfers to the hospital once in June, once in July, twice in August, and once in October 2025. Review of the discharge/transfer evaluations showed that the June, July, and first August transfers did not indicate the HCP was provided a copy of the Bed Hold Policy and Notice of Transfer/Discharge. The second August transfer did not have the Discharge/Transfer Evaluation completed. The October transfer did not indicate the HCP was provided a copy of the Notice of Transfer/Discharge. During interviews, staff stated the transfer/discharge notice and bed hold notice should be given to the HCP each time the resident went to the hospital, documented on the referral/evaluation, and sent by call, email, or mail if the HCP was not in the building. Staff also stated the documentation was incomplete and that follow-up responsibilities were still being worked out.
Diet Order Not Implemented for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure Resident #82 received food prepared in a form that matched the resident’s individual dietary needs. The resident was admitted with diagnoses including obesity, dysphagia, and pneumonitis due to inhalation of food and vomit. The Minimum Data Set dated 11/27/25 showed the resident scored 14 out of 15 on the BIMS and was on a mechanically altered diet. The resident was observed on 1/13/26 with a pureed lunch tray and on 1/14/26 with a breakfast tray containing pureed pancakes and eggs. During interview, the resident stated he/she was still on a puree diet, did not know why it had not changed, wanted it changed, and said the pureed food was not good. The resident also stated he/she only got real food with the speech therapist about once a week and said the diet was supposed to be upgraded but he/she kept getting the same food every day. Review of the SLP notes showed an upgrade to minced and moist consistency was planned on 1/2/26 and later documented as safest on 1/6/26. The physician order record showed a discontinuation of the pureed diet and an upgrade to minced and moist consistency, but the order was entered under the category of Other, the prior order was not discontinued, and the kitchen was not notified with a diet slip. Nursing staff, the DON, consulting staff, and the SLP all stated the order process was not completed correctly, and the nursing note later indicated the resident was to remain on pureed diet until re-evaluated because the facility did not have a minced and moist consistency diet.
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.
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Nursing homes near Norwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Haven Nursing Facility | 0.6 mi | ★★★★★ | 27 | 0 |
| Ellis Nursing Home (the) | 0.9 mi | ★★★★★ | 2 | 0 |
| Charlwell House Health And Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Premier Healthcare At Harrington House | 2.7 mi | ★★★★★ | 0 | 0 |
| Hellenic Nursing & Rehabilitation Center | 3.5 mi | ★★★★★ | 18 | 0 |
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