Oak Knoll Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Framingham, Massachusetts.
- Location
- 9 Arbetter Drive, Framingham, Massachusetts 01701
- CMS Provider Number
- 225682
- Inspections on file
- 25
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Oak Knoll Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dysphagia and a history of choking episodes was not provided with direct supervision during meals, despite repeated recommendations from an SLP and multiple incidents requiring the Heimlich Maneuver. The care plan was not updated to reflect the need for direct supervision, and the resident continued to experience choking episodes, ultimately resulting in death.
A resident with dysphagia, dementia, and a history of choking incidents was not provided with direct supervision during meals as recommended by the SLP. Despite multiple episodes requiring the Heimlich Maneuver, staff only provided distant or informal supervision, and the care plan was not updated to reflect the need for direct oversight. This lack of direct supervision led to another choking event during a meal, resulting in the resident's death.
A facility failed to execute a valid MOLST form for a resident with dementia, as the form was signed by the HCP before the resident was deemed incapacitated by a physician. The HCP activation occurred after the MOLST signing, and the form was not re-addressed upon the resident's admission, leading to the deficiency.
A resident with severe dementia and a history of falls was found using wedge cushions as a restraint instead of the ordered scoop mattress. The facility failed to assess the use of these cushions properly, did not obtain informed consent, and did not review the risks and benefits with the resident's representative. Observations confirmed that the cushions acted as a restraint, preventing the resident from exiting the bed.
The facility failed to transmit MDS assessments within the required 14 days for 17 residents. Comprehensive and non-comprehensive assessments were submitted late due to the absence of the regular MDS Coordinator, with the Corporate MDS Coordinator acknowledging the delay.
A facility failed to complete a PASRR Level I screening before admitting a resident with Major Depressive Disorder and Psychotic Disorder. The screening, which assesses for serious mental illness or developmental disabilities, was conducted after the resident's admission. This was confirmed by a social worker during an interview.
A facility failed to notify the State Mental Health Authority for a Resident Review after a resident with severe dementia and other mental health diagnoses experienced a significant change in condition. The resident was involved in a behavioral incident leading to a psychiatric evaluation at a hospital, but the required PASRR Level II screen was not completed upon their return to the facility.
A facility failed to notify a physician or NP about a resident's high blood sugar levels, despite having orders for regular monitoring and insulin administration. The resident, who was cognitively intact and diagnosed with Diabetes Type II, experienced multiple instances of elevated blood glucose without appropriate medical notification, leading to discomfort and symptoms associated with hyperglycemia. The DON admitted the lack of a specific policy for hyperglycemia and the failure to notify medical staff when levels exceeded 450 mg/dL.
The facility failed to maintain respiratory equipment for two residents, leading to deficiencies in care. One resident's oxygen concentrator filter was not cleaned as required, risking impaired oxygen delivery. Another resident's nebulizer equipment lacked proper maintenance and storage, with no physician's order for care. These oversights highlight failures in adhering to professional standards and infection control practices.
A facility failed to provide appropriate dialysis care for a resident with ESRD, resulting in inadequate monitoring of fluid intake and failure to provide food before dialysis. The resident, on a fluid restriction, experienced inconsistent documentation of fluid intake, with several days below 1000 ml and some days undocumented. The resident also reported not receiving food from staff before dialysis, relying on family-provided snacks. Staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
A facility failed to conduct timely AIMS assessments for a resident receiving antipsychotic medication, as required by their policy. The resident, with diagnoses including Alzheimer's and Major Depressive Disorder, was on Seroquel, but their clinical record lacked an AIMS assessment within the last six months. Interviews confirmed the oversight, highlighting a lapse in monitoring for adverse effects like Tardive Dyskinesia.
A facility failed to follow infection control standards during wound care and G-tube medication administration for a resident with a Stage Four Pressure ulcer. The nurse did not perform hand hygiene after removing gloves and before donning new ones, and did not wear a gown as required by Enhanced Barrier Precautions. The resident had multiple medical conditions, including severe cognitive impairment and dependence on staff for daily activities.
Failure to Revise Dysphagia Care Plan After Repeated Choking Incidents
Penalty
Summary
A deficiency occurred when the facility failed to review and revise a resident's dysphagia care plan in response to repeated choking episodes and recommendations from a Speech Language Pathologist (SLP). The resident, who had a history of dysphagia, dementia, and right-side hemiplegia following a stroke, experienced multiple choking incidents that required staff to perform the Heimlich Maneuver. Despite these events and the SLP's recommendation for direct supervision during meals, the care plan was not updated to include this intervention, and the resident continued to be supervised only from a distance. The resident's care plan was initially updated after a choking episode to downgrade the diet and provide education on safe eating practices. However, after subsequent choking incidents, including those where the resident expelled large pieces of unchewed food, the only intervention added was re-education on taking small bites and alternating with sips. The SLP evaluation specifically recommended direct supervision with oral intake, but this was not incorporated into the care plan, nor was it implemented in practice. Staff interviews confirmed that no one was assigned to provide direct supervision during meals, and documentation of education or further SLP referrals was lacking. The failure to revise the care plan and implement direct supervision as recommended by the SLP persisted despite ongoing choking episodes. Ultimately, the resident choked during a meal, was found unresponsive, and died despite staff intervention. The facility's own investigation and staff interviews confirmed that the SLP's recommendations were not added to the care plan, and no new interventions were implemented following repeated incidents.
Failure to Provide Direct Supervision During Meals for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision to a resident with a history of dysphagia, dementia, and right-sided hemiplegia, who was at increased risk for aspiration and had experienced multiple choking episodes. Despite repeated incidents where the resident choked on food and required the Heimlich Maneuver, staff did not implement the Speech Language Pathologist's (SLP) recommendation for direct supervision during meals. The resident's care plan and documentation did not reflect any changes or additional interventions after the SLP evaluation, which specifically called for direct supervision with all oral intake. Staff interviews and record reviews revealed that although the resident was seated at the Nurses Station during meals, no specific staff member was assigned to provide direct, continuous supervision as recommended. Instead, supervision was informal and staff were often engaged in other tasks such as passing meal trays or administering medications. Multiple staff members, including nurses and CNAs, confirmed that there was no formal assignment for direct supervision, and the resident was only monitored from a distance or within earshot. The lack of direct supervision persisted even after several documented choking incidents, with no evidence that the SLP's recommendations were incorporated into the resident's care plan or daily routine. Ultimately, the resident experienced another choking episode during a meal, which resulted in death despite staff attempts to perform the Heimlich Maneuver. The facility's failure to ensure direct supervision as recommended by the SLP and required by the resident's condition led to the deficiency.
Failure to Execute Valid Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident, specifically concerning the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form. The deficiency involved the MOLST form being signed by the resident's Health Care Proxy (HCP) before the resident was deemed incapacitated by a physician, which rendered the form invalid. The facility's policy requires that a determination of a patient's lack of capacity must be made by a physician in writing before a healthcare proxy can be activated. The resident, who was admitted to the facility with a diagnosis of dementia, had a MOLST form signed by the HCP prior to admission. However, the HCP activation form was dated after the MOLST form was signed, indicating that the HCP was not yet officially activated at the time of signing. There was no evidence that the MOLST form had been re-addressed with the HCP after the resident's admission, and this issue was only identified when brought to the facility's attention by a surveyor. The social worker confirmed that a new MOLST form should have been completed upon the resident's admission, but it was not.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy. The resident, who was admitted with severe dementia, agitation, adjustment disorder with anxiety, and muscle weakness, was observed using wedge cushions as a restraint instead of the ordered scoop mattress. The facility did not appropriately assess or re-assess the use of these wedge cushions, which were used to prevent the resident from exiting the bed and potentially falling. The facility's policy mandates that any device with the potential to act as a restraint must be preceded by a comprehensive assessment, including obtaining informed consent and reviewing the risks and benefits with the resident's representative. However, in this case, the facility did not obtain informed consent for the use of wedge cushions, nor did they review the risks and benefits with the resident's representative. The wedge cushions were placed under the fitted bottom sheet, adjacent to the side rails, leaving no space for the resident to exit the bed, effectively acting as a restraint. Observations by the surveyor and interviews with facility staff, including a CNA, a nurse, the unit manager, and the DON, confirmed that the wedge cushions were used to prevent the resident from falling out of bed. The staff acknowledged that the wedge cushions were not easily removable by the resident and were considered a restraint. Despite this, there was no physician's order for the use of wedge cushions, and the necessary assessments and consents were not completed, leading to the deficiency.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required 14 days after the completion date for 17 residents out of a sample of 23. Specifically, comprehensive MDS assessments for seven residents and non-comprehensive MDS assessments for ten residents were submitted late. The comprehensive assessments, which include the completion of both the MDS Assessment and the Care Area Assessment (CAA) process, were not transmitted within the mandated timeframe. Similarly, non-comprehensive assessments, which do not require the completion of the CAA process, were also delayed in submission. The issue arose during a period when the regular MDS Coordinator was on leave, and the Corporate MDS Coordinator was responsible for overseeing the completion and submission of the facility's MDS assessments. The Corporate MDS Coordinator acknowledged that the assessments for the 17 residents were submitted late according to the standards outlined in the Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual. The delay in submission was confirmed through a review of the Facility's MDS 3.0 Final Validation Report.
Failure to Complete PASRR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission and Resident Review Level I (PASRR Level I) screening was completed prior to the admission of a resident with serious mental illness to the nursing facility. The resident, who was admitted in April 2023, had diagnoses including Major Depressive Disorder and Psychotic Disorder. The PASRR Level I screening, which is intended to assess for serious mental illness or developmental disabilities before admission, was completed after the resident's admission. This oversight was confirmed during an interview with a social worker, who acknowledged that the screening should have been completed prior to the resident's admission.
Failure to Notify State Mental Health Authority After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a Resident Review after a significant change in mental condition occurred for a resident. This resident, who was admitted with diagnoses including severe dementia with agitation, adjustment disorder with anxiety, and major depressive disorder, experienced a significant behavioral incident. The resident punched a CNA in the face during care and subsequently grabbed the CNA's hand, causing scratches. Following this incident, the resident was sent to the hospital for a psychiatric evaluation under Section 12, which allows for involuntary evaluation and admission to a psychiatric unit. Despite the resident's transfer to the hospital for psychiatric evaluation and subsequent readmission to the facility, there was no documented evidence that a PASRR Level II screen was completed. This screen is necessary to determine if the resident requires additional specialized support services due to a change or decline in condition. During interviews, the facility's social worker acknowledged that the PASRR Level II review was not submitted following the resident's hospitalization for psychiatric evaluation.
Failure to Notify Physician of High Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with Diabetes Type II, as per the physician's orders and professional standards of practice. The resident, who was cognitively intact and diagnosed with Diabetes Mellitus, had physician orders for blood glucose monitoring four times a day and insulin administration. Despite these orders, the facility did not notify the physician or nurse practitioner of the resident's consistently high blood glucose levels, which were recorded on multiple occasions. The facility's policy required notification of high blood sugar levels, but there was no evidence that this was done. The Director of Nursing acknowledged that the facility lacked a specific policy for hyperglycemia and that the nursing staff did not notify the physician or nurse practitioner when the resident's blood sugar levels exceeded 450 mg/dL. The resident reported experiencing symptoms associated with high blood sugar, such as dry mouth, sweet-smelling breath, and frequent urination, and recalled a previous hospitalization due to elevated blood sugar levels. The physician confirmed that the order for high blood sugar levels was not documented with a specific numerical value for notification, and there was no record of the nurse practitioner being contacted regarding the resident's elevated blood sugar levels.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in equipment maintenance and infection control. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, the facility did not maintain the oxygen concentrator's air intake gross particle filter according to physician orders and manufacturer guidelines. Despite documentation indicating the filter was cleaned, observations revealed it was covered in a thick layer of gray dust, suggesting it had not been properly maintained. This oversight placed the resident at risk for equipment malfunction and impaired oxygen delivery. Another resident, admitted with pneumonia and acute respiratory failure, did not have an active physician's order for the care and maintenance of nebulizer equipment. Observations showed the nebulizer tubing and face mask were not stored properly, lacking a storage bag and date label, and were left directly on the nightstand. The resident reported using the nebulizer equipment without it being changed, contrary to the facility's policy of weekly changes. The nurse confirmed the equipment had not been changed as required, and the Director of Nursing acknowledged the absence of a physician's order for nebulizer maintenance. These deficiencies highlight the facility's failure to adhere to its own policies and professional standards of practice for respiratory care. The lack of proper equipment maintenance and infection control measures for both residents could lead to significant health risks, including contamination and impaired respiratory function. The facility's documentation practices also came into question, as records did not accurately reflect the care provided.
Inadequate Dialysis Care and Fluid Monitoring for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who was cognitively intact and required assistance for eating, was on a physician-ordered fluid restriction of 1500 milliliters per day. However, the facility did not adequately monitor and assess the resident's fluid intake, as evidenced by inconsistent documentation and failure to maintain accurate records of the resident's fluid intake. The Medication Administration Record (MAR) showed discrepancies in the 24-hour fluid intake totals, with several days of intake below 1000 ml, some days with no documentation, and instances where the intake exceeded the prescribed limit. Additionally, the facility did not provide food items to the resident prior to dialysis as indicated in the care plan and according to the resident's preferences. The resident reported not receiving any food or snacks from the facility staff before leaving for dialysis, resulting in hunger and discomfort. The resident's family had to provide crackers for the resident to eat. Interviews with staff revealed a lack of communication and understanding regarding the resident's fluid restriction and dietary needs, with some staff unaware of the fluid restriction and others unsure of the resident's food preferences. The facility's policies on fluid restrictions and dialysis care were not effectively implemented, leading to inadequate monitoring and provision of care for the resident. The failure to document and communicate the resident's fluid intake and dietary needs put the resident at risk for complications related to fluid imbalance and inadequate nutrition, particularly given the resident's history of diabetes and hypoglycemic episodes.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner for a resident receiving antipsychotic medication, as required by their policy. The AIMS assessment is crucial for monitoring adverse consequences and side effects, such as Tardive Dyskinesia, in residents taking antipsychotic medications. The resident in question was admitted with diagnoses including Alzheimer's disease, Major Depressive Disorder, Anxiety, Restlessness, Agitation, and Insomnia. Despite receiving Seroquel, an antipsychotic medication, on a routine basis, the resident's clinical record did not show an AIMS assessment within the last six months. Interviews with the Unit Manager and the Director of Nursing confirmed that the last AIMS assessment was completed several months prior, and it was acknowledged that these assessments should be conducted every six months for residents on antipsychotic medications.
Infection Control Lapses During Wound Care and G-tube Administration
Penalty
Summary
The facility failed to adhere to infection control standards during a wound care procedure for a resident with a Stage Four Pressure ulcer. The nurse involved did not perform appropriate hand hygiene on multiple occasions, increasing the risk of wound contamination and infection. Specifically, the nurse did not wash hands or use hand sanitizer after removing soiled gloves and before donning new gloves, despite handling potentially contaminated items such as a urinary drainage bag that had been on the floor. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) during medication and fluid administration through a gastrostomy tube for the same resident. The nurse administering the medication did not wear a gown as required by the EBP guidelines, despite handling the resident's feeding tube, which is considered a high-contact activity. The nurse acknowledged the oversight but failed to follow the established protocol. The resident involved had multiple medical conditions, including a Stage Four Pressure ulcer, neuromuscular dysfunction of the bladder, dysphagia, and a gastrostomy tube. The resident was severely cognitively impaired and dependent on staff for activities of daily living. The failure to follow infection control protocols during wound care and medication administration posed a risk of infection to the resident.
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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