Oc Milford Gardens Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Massachusetts.
- Location
- 10 Veterans Memorial Drive, Milford, Massachusetts 01757
- CMS Provider Number
- 225562
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Oc Milford Gardens Llc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and dependence on staff for care was allegedly handled roughly by a CNA, resulting in bruising to the resident’s arms, according to the resident’s family. A nurse heard the family member loudly accuse the CNA of abuse but did not report the allegation to a supervisor or administration. The weekend Nursing Supervisor was later informed by the same family member that the CNA had not properly cleaned the resident and was believed to be responsible for the bruising, yet she did not immediately notify the administrator or DON as required by the facility’s abuse policy, instead leaving a written statement under the administrator’s door. As a result, the administrator did not learn of the alleged abuse until informed by police, demonstrating a failure to follow the facility’s mandated immediate abuse reporting procedures.
A resident with dementia, severe cognitive impairment, and generalized muscle weakness, who was dependent on staff for care, was the subject of a family member’s allegation that a CNA had been rough during care and caused bruising on the resident’s arms. A nurse heard the family member loudly accuse the CNA of abuse but did not report the allegation to a supervisor or administration, and there was no documentation of any report at that time. A nursing supervisor later received related concerns from the family but also did not immediately notify administration. As a result, the administrator did not learn of the abuse allegation until informed by police, and the allegation was not reported to the state agency within the facility’s required 2-hour timeframe.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was allegedly handled roughly by a CNA, causing bruising to the arms, as reported by a family member. A nurse heard the family member accuse the CNA of abuse but did not report the allegation to supervisory or administrative staff. The nursing supervisor later learned that the family member believed the CNA caused the bruising but did not immediately notify administration or initiate an investigation, and did not remove the CNA from duty at that time. This inaction resulted in the CNA continuing to work with residents and delayed the start of the facility’s abuse investigation.
A facility failed to implement a 40-day Vancomycin taper for a resident with C. diff, leading to worsening of a stage IV pressure ulcer. Despite clear hospital discharge recommendations, the treatment was not initiated for 19 days, during which the resident experienced frequent diarrhea. Interviews revealed a communication breakdown among staff, resulting in the delay of necessary care.
The facility failed to notify the physician and/or responsible party of significant changes in condition for four residents, leading to deficiencies in care. One resident experienced a delay in treatment for C. diff, resulting in worsening of a pressure ulcer. Two residents had significant weight loss without physician notification, and another resident's guardian was not informed of a fall and hospital transfer. These failures highlight inadequate communication and documentation.
Two residents in a facility did not receive appropriate wound care for their pressure ulcers. One resident with a stage IV sacral ulcer did not receive the recommended Santyl treatment, and a Vancomycin taper for C. diff was not initiated. Another resident with unstageable heel ulcers did not have their treatment plan updated as recommended by the wound NP. Staff interviews revealed lapses in communication and implementation of wound care orders.
The facility failed to address grievances from Resident Council Meetings regarding evening snacks and non-English speaking agency staff. The Administrator signed off on response forms without follow-up, and the Activities Director did not include unresolved issues in subsequent meetings. Residents reported these issues remained unresolved months later.
The facility failed to properly document and resolve grievances from residents, including issues with staff responsiveness, missing personal items, roommate disturbances, and care needs. Grievance forms lacked investigation details, findings, and confirmation of resolutions, as required by the facility's policy. The Administrator acknowledged these documentation gaps.
Two residents in the facility experienced improper catheter care, leading to deficiencies in infection control. A resident with severe cognitive deficits had their catheter drainage bag repeatedly observed on the floor, contrary to guidelines. Another resident, also severely cognitively impaired, had their drainage bag on the floor and above bladder level, risking complications. Staff interviews confirmed the failure to follow proper procedures, resulting in a deficiency in infection control practices.
A facility failed to document the physician's response to a pharmacist's medication regimen review (MRR) recommendations for a resident with dementia and other conditions. Despite multiple recommendations for medication adjustments and lab tests, the facility could not provide documentation of the physician's review, except for one instance. The Director of Nurses confirmed that these forms should have been retained in the resident's medical record.
The facility failed to properly store and label drugs and biologicals. A resident had unsecured medications in their room, including a nebulizer and Tums, without proper assessments for self-administration. Additionally, a Lantus insulin pen and Liquid Protein supplements were found unlabeled with the date opened. Staff acknowledged these oversights, which contravened facility policies.
The facility failed to follow food safety and sanitation standards, risking foodborne illness among residents. Observations showed improper labeling and storage of food items in nourishment kitchenettes, with missing resident identification and use-by dates. Additionally, microwaves were found unclean, with food splatter and dark substances. The Food Service Director confirmed that dietary and nursing staff are responsible for labeling and checking expiration dates, but these duties were not consistently fulfilled.
A resident with a suprapubic catheter was observed multiple times with the catheter drainage bag visible from the hallway, without a privacy bag, compromising their dignity. Staff interviews confirmed the expectation for privacy bags to be used, but the facility was out of stock, leading to the deficiency.
A facility failed to accurately complete a Level 1 PASARR for a resident with severe mental illness, including bipolar disorder and PTSD. The PASARR, completed by the MDS nurse, incorrectly indicated no serious mental illness diagnoses, despite these being documented in the resident's hospital discharge summary and MDS assessment. This error was confirmed by the Director of Social Services and the MDS nurse, resulting in the absence of a necessary Level 2 PASARR.
A facility failed to follow professional standards when a CNA administered a medicated cream to a resident, which should have been done by a nurse. Additionally, a physician's order for Trazodone for another resident was incomplete, lacking the medication's strength. These actions were against the facility's policies and state regulations.
Two residents in an LTC facility were found to have deficiencies related to safety and medication storage. One resident's emergency oxygen tank was not secured, posing a safety hazard, and their inhalers were left unsecured at the bedside. Another resident's rescue inhaler was also left unsecured. Staff interviews confirmed that these practices were against the facility's policies, which require medications to be stored securely.
A facility failed to document a risk/benefit analysis for the continued use of Amitriptyline in a resident with severe cognitive impairment, despite a pharmacist's recommendation for a safer alternative. The physician acknowledged the recommendation but did not provide the required documentation, leading to a deficiency in compliance with the facility's psychoactive medication policy.
A facility failed to maintain an effective infection prevention and control program, as staff did not adhere to PPE protocols for two residents on contact precautions. One resident with C. diff was assisted by a CNA without gloves or a gown, despite clear signage. Another resident with a feeding tube did not receive proper gown usage during gastrostomy care. Interviews revealed staff misunderstandings about PPE requirements, confirmed by the DON.
Failure to Immediately Report Alleged Abuse as Required by Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy requiring immediate reporting of alleged abuse to administration. The facility’s abuse policy, revised March 2023, stated that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, must be reported immediately to the administrator and DON using the chain of command, with a two-hour requirement to report allegations to the Department of Public Health and local law enforcement. Resident #1, admitted in December 2025 with dementia and generalized muscle weakness, had a comprehensive MDS dated 12/10/25 indicating severe cognitive impairment and dependence on staff for care needs. On 12/13/25, Nurse #1 heard a family member yelling and swearing at CNA #1, accusing him of abusing the resident and causing bruises on the resident’s arms. Nurse #1 stated she stepped away from the situation because of the yelling and did not want to be involved, and there was no documentation that she notified her supervisor or administrative staff of the altercation or the abuse allegation at that time. The next day, the weekend Nursing Supervisor reported that the family member initially complained that CNA #1 had not properly cleaned the resident, and later told her that she believed CNA #1 was responsible for bruises on the resident’s arms and wanted to speak with him. The Nursing Supervisor did not immediately contact the administrator or DON as required by policy, but instead placed a written statement under the administrator’s door that day. The DON stated that facility policy requires all staff to immediately report any suspicion or allegation of abuse to their supervisor or administration and confirmed that the weekend Nursing Supervisor, who was aware of the allegation on 12/14/25, did not immediately report it to her or the administrator. The administrator reported that he was not made aware of the allegation of staff abuse involving the resident until 12/15/25, when police arrived and informed him that the resident’s family had reported rough handling by CNA #1 that allegedly caused bruising on the resident’s arm. This sequence of events shows that staff who became aware of the allegation on 12/13/25 and 12/14/25 did not follow the facility’s abuse reporting policy.
Failure to Timely Report Allegation of Abuse to Administration and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was immediately reported to administration so it could be reported to the state survey agency within the required timeframe. Facility policy, revised March 2023, required that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, misappropriation of resident property, and exploitation, be reported immediately to the administrator and DON using the chain of command, and that all abuse allegations require immediate action with notification to the Department of Public Health and local law enforcement no later than two hours after an abuse allegation is received. The resident involved had dementia, generalized muscle weakness, severe cognitive impairment, and was dependent on staff to meet care needs, as documented in a comprehensive MDS assessment dated 12/10/25. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing the CNA of abusing the resident and causing bruises on the resident’s arms. The nurse stated she stepped away because the family member was yelling and she did not want to be involved, and she did not take any action or notify a supervisor or administration; there was no documentation that she reported the allegation. The nursing supervisor reported that on 12/13/25 the family member only complained that the CNA had not properly cleaned the resident, and that it was not until the next day that the family member linked the CNA to bruises on the resident’s arms; the supervisor also did not immediately notify administration. The administrator and DON both stated that staff are expected to report any suspicion or allegation of abuse immediately so that administration can report to DPH and police within two hours. However, the administrator did not become aware of the allegation until 12/15/25 when police arrived with the family and reported the allegation of rough care and bruising, and the HCFRS report was submitted that same day, resulting in the allegation being reported to the state agency two days after staff were first made aware of the abuse allegation.
Failure to Immediately Report and Act on Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of physical abuse involving a resident with severe cognitive impairment who was dependent on staff for care. The resident, admitted in December 2025 with dementia and generalized muscle weakness, had an MDS assessment indicating severe cognitive impairment and total dependence on staff. The facility’s abuse policy, revised March 2023, required that when abuse is observed, reported, or suspected, residents must be immediately protected from the alleged abuse and the employee immediately suspended pending investigation. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing him of abusing the resident and causing bruises on the resident’s arms. The nurse stated she removed herself from the situation because of the yelling and did nothing further, and there was no documentation that she notified a supervisor or administrative staff of the altercation or the abuse allegation. On the same date, the nursing supervisor reported that the family member only complained that the CNA had not properly cleaned the resident and did not mention abuse. The next day, the family member told the nursing supervisor she wanted to talk to the CNA because she believed he was responsible for bruises on the resident’s arms. The nursing supervisor did not immediately report this allegation to administration, and there was no documentation that she initiated an investigation or had the CNA removed from the schedule at that time. The DON later stated that any time an allegation of abuse is made against a staff member, the staff member must be suspended immediately to protect the resident and other residents, and acknowledged that the nursing supervisor should have reported the allegation immediately. The administrator reported first learning of the allegation on 12/15/25, at which time the CNA was not working, and he then obtained a statement and suspended the CNA. As a result of the nurse’s and nursing supervisor’s inaction, the CNA continued to work and interact with residents, and there was a two-day delay in the facility initiating an investigation into the abuse allegation.
Failure to Implement Antibiotic Treatment for C. diff
Penalty
Summary
The facility failed to manage and deliver safe nursing care by not implementing treatment recommendations for a resident diagnosed with Enterocolitis due to Clostridium Difficile (C. diff). The resident, who was admitted with diagnoses including C. diff, a stage IV pressure ulcer, and chronic kidney disease, returned from a hospital stay with a recommendation for a 40-day Vancomycin taper. However, this recommendation was not reviewed or implemented by the facility's in-house physician or nursing staff for 19 days following the resident's discharge from the hospital. During this period, the resident experienced frequent episodes of diarrhea, which were documented by the Certified Nursing Assistant (CNA) on multiple occasions. The resident's stage IV pressure ulcer on the sacrum worsened, as noted by the wound consultant, who reported increased wound measurements, odor, and drainage. The physician and wound consultant both acknowledged that the resident's loose stools and C. diff infection negatively impacted the wound healing process. Interviews with the facility's staff, including the physician, unit manager, and director of nursing, revealed a breakdown in communication and procedure. The hospital discharge summary clearly indicated the need for a Vancomycin taper, but this was not communicated effectively to the physician or nurse practitioner for implementation. The director of nursing confirmed that the discharge summary should have been reviewed and clarified with the physician, and acknowledged the delay in starting the necessary antibiotic treatment for the resident.
Failure to Notify Physician and Guardian of Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician and/or responsible party of significant changes in condition for four residents, leading to deficiencies in care. For one resident, the facility did not inform the physician of treatment recommendations for a 40-day Vancomycin taper following a diagnosis of C. diff after hospitalization. This oversight resulted in a delay of 19 days before the treatment was initiated, during which time the resident experienced worsening of a stage IV pressure ulcer due to recurrent diarrhea. Another resident experienced significant weight loss, but the facility did not notify the physician or document such notification in the medical record. The resident had lost approximately 99 pounds since admission, and although the dietitian was aware, there was no system in place to ensure the physician was informed of the weight loss, which is a critical aspect of the resident's care. Additionally, a third resident also experienced significant weight loss without the physician being notified. The facility's care plan required notification of the physician for any significant weight changes, but this was not followed. Lastly, a resident who suffered a fall and was transferred to the hospital did not have their guardian notified of the incident, as required by the facility's policy. These failures highlight a pattern of inadequate communication and documentation regarding changes in residents' conditions.
Deficiencies in Wound Care Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, leading to deficiencies in the treatment of pressure ulcers. Resident #65, who was admitted with a stage IV pressure ulcer on the sacrum, did not receive the recommended wound care treatment as prescribed by the Consulting Wound Nurse Practitioner (NP). The physician's orders and the Treatment Administration Record (TAR) did not include the use of Santyl, a critical component of the treatment plan, and there was a lack of clarity regarding the use of Dakin's solution and alginate dressing. Additionally, a 40-day Vancomycin taper for the treatment of C. diff was not initiated upon the resident's return from hospitalization, which could have impacted the healing process of the pressure ulcer. Resident #68, who had unstageable pressure ulcers on both heels, also did not receive the updated treatment plan recommended by the Wound Care Nurse Practitioner. The physician's orders continued to reflect an outdated treatment plan, failing to incorporate the new recommendations made on 11/22/24. This oversight was attributed to a lapse in communication and implementation of the wound NP's recommendations, as the staff member responsible for updating the orders was not present during the NP's rounds. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed a breakdown in the process of updating and implementing wound care orders. The staff acknowledged the discrepancies between the NP's recommendations and the actual orders in the residents' medical records. The failure to follow through with the recommended treatment plans for both residents highlights a significant deficiency in the facility's wound care management practices.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances brought forward during Resident Council Meetings held on 9/29/24 and 10/18/24. During these meetings, residents complained about not being offered evening snacks and the presence of too many agency staff who did not speak English. The facility's policy requires the use of a Resident Council Response Form to track issues and their resolution, with the responsible department addressing the concerns. However, the Administrator signed off on the forms without providing follow-up to the Resident Council regarding the efforts made to address these grievances. During a resident group meeting on 12/4/24, residents reported that the issues raised in September and October remained unresolved. The Activities Director, who facilitates the Resident Council meetings, admitted to not following up on the residents' concerns and failing to include them in the discussion of old business at subsequent meetings. The Administrator, who is the grievance official, acknowledged that he did not provide documented evidence of resolutions to the complaints and confirmed that the grievances should have been reviewed at the next month's meetings, but they were not.
Inadequate Documentation and Resolution of Resident Grievances
Penalty
Summary
The facility failed to ensure proper documentation and resolution of grievances filed by residents, as evidenced by the review of the grievance book and interviews with the Administrator and Consultant Staff. The facility's policy requires that grievances be documented with all steps of the resolution process, including investigation findings, conclusions, and whether the grievance was confirmed or not. However, for several residents, these steps were not adequately documented, leading to incomplete grievance records. For instance, Resident #29 reported that a Certified Nursing Assistant ignored a request, but the grievance form lacked documentation of an investigation or resolution. Similarly, Resident #278's grievance about missing cheese packages was not followed up with documentation of reimbursement or satisfaction with the resolution. Resident #277's complaint about a noisy roommate was not thoroughly investigated, and the grievance form did not include a summary of findings or staff interviews. Additionally, Resident #47's grievances regarding a bed sore and the need for a two-person assist were not fully documented, lacking confirmation of the grievances and satisfaction with the resolutions. Resident #72's grievances about colostomy bag changes and a wet bed were also inadequately documented, with missing investigation details and resolution satisfaction. The Administrator acknowledged these documentation gaps, indicating a failure to adhere to the facility's grievance policy.
Improper Catheter Care and Infection Control Deficiency
Penalty
Summary
The facility failed to provide proper indwelling catheter care for two residents, leading to deficiencies in infection control prevention. For Resident #330, the catheter drainage bag was repeatedly observed in direct contact with the floor, which is against the guidelines set by the Centers for Disease Control and Prevention and the facility's own policy. Despite having severe cognitive deficits and requiring an indwelling catheter, the resident's catheter care was not maintained according to professional standards, as evidenced by multiple observations of the drainage bag on the floor over two days. Similarly, Resident #64, who was severely cognitively impaired and had a history of cerebral infarction and obstructive uropathy, also experienced improper catheter care. The resident's catheter drainage bag was observed on the floor and positioned above the bladder level, which could lead to potential complications. The facility's staff, including CNAs and nurses, acknowledged that the drainage bags should be kept off the floor and below the bladder level to prevent infection and backflow of urine. Interviews with various staff members, including CNAs, nurses, the unit manager, and the infection preventionist, confirmed that the facility's procedures for catheter care were not followed. The staff recognized the importance of maintaining the drainage bags off the floor and below the bladder level to prevent infection and other complications. However, the observations made by the surveyor indicated a failure to adhere to these procedures, resulting in a deficiency in the facility's infection control practices.
Failure to Document Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly medication regimen review (MRR) for a resident was properly documented and included in the medical record. The facility's policy requires that the consulting pharmacist's observations and recommendations be made available to the Director of Nursing and other relevant staff, and that these recommendations be addressed before the next MRR. However, for one resident, the facility did not provide documentation of the physician's response to the pharmacist's recommendations for several months, despite the pharmacist making multiple recommendations regarding medication adjustments and laboratory tests. The resident in question was admitted with diagnoses including dementia, a fracture of the second cervical vertebra, and mild cognitive impairment. The pharmacist made several recommendations over a period of months, including re-evaluating the use of certain medications and conducting specific laboratory tests. Despite these recommendations, the facility was unable to provide documentation showing that the physician had reviewed and responded to these recommendations, except for one instance. This lack of documentation was confirmed during an interview with the Director of Nurses, who acknowledged that the completed forms should have been retained in the resident's medical record.
Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed in several instances. For Resident #41, a portable nebulizer device and a bottle of Tums were found unsecured in the resident's room. Despite the resident's cognitive intactness and a self-administration assessment for inhaled medications, there was no assessment for oral medications like Tums. The facility's policy requires medications to be stored securely, yet the nebulizer and Tums were repeatedly found unsecured, and staff were unaware of the resident's possession of these items. Additionally, during a review of the medication cart on the Elm Unit, a Lantus insulin pen was found opened but not labeled with the date it was opened or the date it should be discarded. This oversight was acknowledged by Nurse #5, who confirmed that the insulin pen should have been labeled according to the facility's policy, which mandates that insulin be discarded 28 days after opening. Furthermore, the facility failed to label Liquid Protein supplements with the date opened. Nurse #6 administered Liquid Protein to a resident without the bottle being marked with the date it was opened, despite the product having a three-month shelf life from the date of opening. This issue was also observed on the medication cart, where an opened bottle of Liquid Protein was not dated. Nurse #5 admitted to not being informed about the requirement to label the Liquid Protein with the date opened, and the DON confirmed that it should have been marked.
Food Safety and Sanitation Deficiencies in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illness among residents. Observations revealed that food products in the nourishment kitchenettes across three units were not properly labeled with resident identification or use-by dates. Specifically, items such as Premier Protein Shakes, V8 Juice, and various frozen food packages lacked resident identification, and some items were past their expiration dates. Additionally, Tupperware containers with food products had ice buildup and were missing use-by dates, indicating improper storage practices. The facility's policy requires that food brought in by family or visitors be labeled with the resident's name and the date it was brought in, and that it should be discarded after three days. However, the surveyor found multiple instances where these guidelines were not followed. For example, a bottle of Coffee Milk was found with a use-by date that had already passed, and several Tupperware containers were stored without proper labeling. These lapses in protocol suggest a lack of oversight in ensuring that food safety standards are consistently met. Furthermore, the cleanliness of the equipment in the nourishment kitchenettes was substandard. Microwaves in the Elm Unit were observed to have food splatter and a dark brown/black substance on the inside, indicating inadequate cleaning practices. The Food Service Director acknowledged that dietary staff are responsible for checking labels and expiration dates during stocking, while nursing staff should label items brought in by families. However, the observed deficiencies indicate a breakdown in these responsibilities, contributing to the potential risk of foodborne illness among residents.
Failure to Maintain Resident Dignity Due to Lack of Privacy Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with a suprapubic catheter by not providing a privacy bag for the catheter drainage bag. The resident, who was admitted in June 2021 with neuromuscular dysfunction of the bladder and diabetes mellitus with neuropathy, was observed multiple times with the catheter drainage bag visible from the doorway and hallway, without any cover to ensure privacy. The resident was moderately cognitively impaired, scoring 8 out of 15 on the Brief Interview for Mental Status. Interviews with various staff members, including nurses and certified nurse aides, confirmed that the catheter drainage bag should have been kept in a privacy bag at all times to prevent visibility and maintain the resident's dignity. The Unit Manager acknowledged that the facility was out of privacy bags and was awaiting a delivery, but stated that the drainage bag should have been positioned in a way that it was not visible from the hallway. The Staff Development Coordinator also confirmed that the staff are responsible for ensuring that catheter drainage bags are not in plain view to preserve residents' dignity and privacy.
Inaccurate PASARR Completion for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for a resident with severe mental illness. The resident, admitted in October 2023, had diagnoses including bipolar disorder and PTSD, which were documented in the hospital discharge summary and the Minimum Data Set (MDS) assessment. However, the PASARR completed by the facility's MDS nurse prior to admission incorrectly indicated that the resident did not have any serious mental illness diagnoses, such as bipolar disorder or PTSD. The discrepancy was identified during a review of the PASARR and confirmed through interviews with the Director of Social Services and the MDS nurse. The Director of Social Services acknowledged that the PASARR was completed incorrectly and did not reflect the resident's mental illnesses as it should have. The MDS nurse also admitted that the PASARR did not match the resident's known active diagnoses as reflected on the MDS at the time of admission or currently. This error resulted in the resident not having a Level 2 PASARR completed, which would typically be required for someone with the resident's psychiatric history and diagnoses.
Medication Administration and Order Completeness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in two specific instances involving residents. For one resident, a Certified Nursing Assistant (CNA) improperly administered a medicated cream, Lidocaine Pain Relief Cream Plus Menthol, which is considered a medication. The resident, who was cognitively intact and experiencing frequent pain, requested the CNA to apply the cream to their lower back. The CNA complied, unaware that administering medicated creams is outside their scope of practice, as confirmed by interviews with the nursing staff and the Director of Nursing (DON). In another instance, the facility did not ensure that a physician's order for Trazodone, an antidepressant, was complete. The order for the resident, who had severe cognitive impairment and was receiving psychotropic medication daily, lacked the strength of the medication. This omission occurred when the order was renewed, and it was noted by both a nurse and the DON during a review of the resident's medical record. These deficiencies highlight a lack of adherence to established protocols regarding medication administration and order completeness. The facility's policies and state regulations clearly outline the responsibilities of nursing staff and the requirements for medication orders, which were not followed in these cases.
Deficiencies in Safety and Medication Storage
Penalty
Summary
The facility failed to ensure a safe environment free from potential safety hazards for two residents, leading to deficiencies in the storage and security of medical equipment and medications. For one resident, the facility did not properly secure an emergency oxygen tank, which was observed multiple times standing unsecured in the resident's room. This failure to secure the oxygen tank was acknowledged by both the Unit Manager and the Director of Maintenance, who confirmed that the tank should have been stored in a cylinder stand or attached to the wall to prevent it from falling and causing a safety hazard. Additionally, the same resident was allowed to keep inhalers at the bedside without a lock box or any means of securing them, contrary to the facility's policy on medication storage. The resident, who was cognitively intact and permitted to self-administer medications, kept the inhalers on the overbed table, accessible to others. Interviews with nursing staff and the Unit Manager confirmed that the inhalers should have been secured in a locked compartment to prevent unauthorized access, but this was not done. Another resident also kept a rescue inhaler at the bedside without any means of securing it. Despite being cognitively intact and having permission to self-administer the inhaler, the resident's inhaler was left unsecured on the overbed table. Interviews with nursing staff and the Director of Nurses revealed that the facility's process for self-administration of medications was not fully implemented, as the inhaler was not secured in a lock box as required by the facility's policy.
Failure to Document Risk/Benefit Analysis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not document a risk/benefit analysis for the continued use of the antidepressant medication Amitriptyline, despite a recommendation from the pharmacist to consider a safer alternative. The resident, who was admitted in September 2023, had diagnoses including major depression, dementia with psychotic disturbance, and anxiety. The Minimum Data Set assessment indicated severe cognitive impairment, and the resident received psychotropic medication daily. The pharmacist's Medication Regimen Review highlighted that Amitriptyline should be avoided in elderly patients due to its anticholinergic properties and potential side effects, suggesting alternatives such as SSRIs and SNRIs. Although the physician acknowledged the pharmacist's recommendation by checking a pre-printed response, there was no documented risk/benefit analysis in the resident's medical record. Interviews with the Unit Manager and Physician confirmed the absence of such documentation, indicating a failure to comply with the facility's policy on psychoactive medication use.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents on contact precautions. For Resident #65, who was admitted with diagnoses including C. diff and a stage IV pressure ulcer, staff did not adhere to the required personal protective equipment (PPE) protocols. Despite the presence of a Contact Precautions Plus sign outside the resident's room, a Certified Nursing Assistant (CNA) was observed assisting the resident with their lunch without wearing gloves or a gown. Interviews with the CNA, a nurse, and the unit manager revealed a misunderstanding of the PPE requirements, with some staff believing that gowns and gloves were only necessary during direct care, contrary to the facility's policy. In the case of Resident #327, who was admitted with severe protein-calorie malnutrition and diabetes mellitus, and had a feeding tube, staff also failed to follow enhanced barrier precautions (EBP). The resident's room had an EBP sign indicating the need for gloves and a gown during high-contact care activities, including gastrostomy care. However, a nurse was observed administering medications and enteral feeding via the gastrostomy tube without donning a gown, although gloves were worn. Interviews with the nurse and unit manager confirmed a lack of clarity regarding the necessity of wearing a gown for these procedures. The Director of Nursing (DON) confirmed that both residents were on specific precautions and that staff were expected to adhere to the facility's infection control policies. The observations and interviews highlighted a gap in staff understanding and implementation of the required PPE protocols, leading to the deficiencies noted by the surveyors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
