Oc Reading Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Reading, Massachusetts.
- Location
- 1364 Main Street, Reading, Massachusetts 01867
- CMS Provider Number
- 225431
- Inspections on file
- 22
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Oc Reading Center Llc during CMS and state inspections, most recent first.
A resident who was cognitively intact and dependent on staff for care reported being roughly handled, spoken to in a rude and disrespectful manner, and laughed at by a CNA during overnight care. The resident's account was consistent across multiple interviews and was substantiated by the facility's internal investigation, which found that the care provided did not meet the required standards of dignity and respect.
Nurses and nurse aides lacked the necessary competencies to provide care that maximized the well-being of each resident, resulting in care that did not meet individualized needs.
A resident with a history of suicidal ideation and depression was not provided with appropriate behavioral health services at the facility. Despite recommendations for psychiatric consults and medication management, the facility failed to implement a care plan or make necessary referrals for psychotherapy. The resident attempted suicide at the facility, and upon readmission, the plan of care was not updated. Interviews revealed a lack of communication and follow-up by facility staff regarding the resident's mental health needs.
A facility failed to provide appropriate treatment for a resident with a history of depression and suicidal ideation. Despite recommendations for psychiatric consults and medication management, the facility did not develop or update a care plan addressing the resident's needs. The resident expressed active suicidal ideation and attempted suicide, yet the facility did not implement necessary interventions or communicate treatment plans effectively. Staff interviews revealed a lack of awareness and communication regarding the resident's history and needs.
The facility failed to develop comprehensive care plans for two residents, one with suicidal ideation and another with incontinence. The resident with SI did not have a care plan addressing their condition, leading to a suicide attempt. The other resident lacked a care plan for incontinence, resulting in inadequate care and dissatisfaction. Staff were unaware of these issues, and the facility did not follow its policies for care planning.
A resident at high risk for pressure ulcers did not receive necessary interventions, leading to the reopening of a previously healed ulcer. The facility failed to offload the resident's heels and maintain correct air mattress settings. Additionally, wound care orders for a new ulcer were not obtained, and weekly assessments of a deep tissue injury were not conducted. Documentation of weekly skin assessments was also inconsistent.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to multiple deficiencies such as not implementing pressure ulcer prevention, failing to assess wounds weekly, and not performing hand hygiene during wound care. None of the three nurses reviewed had completed wound care competencies in the past year, partly due to the absence of a staff development nurse.
The facility failed to update care plans or conduct falls assessments for two residents after falls, resulting in deficiencies in care. One resident experienced multiple falls, including one with a fracture, without care plan revisions. Another resident had a fall resulting in a fracture, but their care plan was not updated. The facility's fall reduction policy was not followed, indicating a deficiency in managing fall risks and care plan updates.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis. The resident's dialysis communication book often lacked post-dialysis weights, and staff did not consistently follow up on missing information. Interviews revealed a lack of communication with the dialysis center and confusion about the facility's responsibility in managing the resident's dialysis care.
The facility failed to meet professional standards for two residents by not implementing physician orders for wound care and heel protection. One resident did not receive daily wound dressings as ordered, and another was observed without heel protection booties despite physician orders. Staff interviews confirmed the orders were not followed, and there was no documentation of refusal by the residents.
The facility failed to provide scheduled weekly showers to three residents, despite their dependency on staff for bathing due to medical conditions like acute and chronic respiratory failure, cerebral palsy, and muscle weakness. Residents reported not receiving showers for extended periods, and documentation confirmed the lack of showers, with no records of refusals. The DON was aware of the issue but believed it was resolved, yet no refusals were documented.
A resident experienced a delay in obtaining hearing aids due to the facility's failure to timely implement ear wax removal, as recommended by an audiologist. Despite the resident's intact cognition and minimal hearing difficulty, the treatment was delayed for nearly nine months, affecting the resident's access to necessary hearing services.
A resident in a LTC facility, who was cognitively intact and always incontinent, repeatedly had to eat breakfast while sitting in a soiled brief. Despite the resident's requests for incontinence care before meals, staff did not provide assistance, citing mealtime as a reason. The facility's policy on dignity and quality of life was not followed, and the resident's medical record lacked a care plan for incontinence.
The facility failed to notify the physician and obtain wound care orders for two residents with significant skin conditions. One resident had a pressure ulcer and a skin tear, while another had pressure wounds on the buttocks. Despite facility policy, the provider was not informed, and no treatment orders were obtained, leading to deficiencies in care.
A resident repeatedly complained about staff sleeping during night shifts, but the facility failed to document or address these grievances according to its policy. Despite the resident's efforts, including providing photographic evidence, the issue persisted, with other residents also reporting similar observations. Interviews revealed inconsistencies in grievance documentation, and the DON acknowledged awareness of the issue but lacked documentation of any investigations.
A resident with severe cognitive impairment and mobility issues was involved in an alleged abuse incident during an incorrect transfer by a nurse. The facility failed to update the resident's care plan and did not document follow-up by the Social Worker, as required by their abuse policy. The DON admitted to not updating the care plan and was unsure about the Social Worker's follow-up.
The facility failed to investigate allegations of neglect for two residents. One resident, dependent on staff for toileting, reported being told they would be changed later, with no proper investigation documented. Another resident, requiring substantial assistance, was left in a chair for nine hours despite requests to be put back to bed. The DON acknowledged these grievances but did not provide investigation documentation, viewing them as customer service issues.
A facility failed to review and address pharmacy recommendations for a resident with severe cognitive impairment. The pharmacist recommended evaluating the need for Enoxaparin and adjusting the timing of Atorvastatin. These recommendations were not communicated to the physician due to the Nurse Unit Manager's absence, resulting in a delay in implementation.
A facility failed to maintain a medication error rate below 5%, with a nurse making two errors out of 31 opportunities. A resident received incorrect calcium carbonate and ferrous sulfate without dosage clarification. The nurse was unaware of the need to clarify orders, and the correct type of calcium carbonate was unavailable. The resident had severe cognitive impairment and was admitted with diabetes and hypertension.
The facility failed to store medications in their original, labeled containers, as observed by a surveyor and a nurse who found unlabeled pills in medication cups on a cart. A nurse admitted to pouring the medications earlier but not administering them due to resident unavailability, intending to do so later. The DON confirmed that medications should not be stored in this manner and should be discarded if not administered.
The facility failed to maintain accurate medical records and complete daily documentation for three residents. A resident with diabetes and venous ulcers had wound care documented as completed when it was not, with no record of refusal or rationale. Additionally, two residents had incomplete documentation of bathing tasks over three months, despite requiring assistance. Interviews confirmed significant missing documentation, which the DON acknowledged.
The facility did not develop a QAPI plan to address residents' concerns about not receiving showers. Resident Council minutes from several meetings indicated that showers were not happening as scheduled. During a Resident Group meeting, most participants reported not having had a shower in a long time. The DON was unaware of the issue because the Activities Director had not shared the meeting minutes, preventing the issue from being addressed in the QAPI process.
A nurse in an LTC facility failed to follow proper hand hygiene protocols during wound and tracheotomy care. The nurse did not perform hand hygiene after removing gloves while treating a resident's wounds and did not change gloves after contact with tracheotomy secretions. The nurse acknowledged the oversight, and the DON confirmed the correct procedures.
The facility failed to provide written notice to residents before room changes or new roommate assignments, affecting 21 alert and oriented residents. Despite a policy requiring verbal and written notice, no documentation was found in clinical records, and interviews confirmed the lack of notice. The Administrator and DON admitted that a corporate directive led to immediate relocations without following the policy, preventing residents from being informed or discussing changes with family.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and able to communicate needs, was not treated with dignity and respect by a Certified Nurse Aide (CNA) during an overnight shift. The resident, who had multiple sclerosis, paraplegia, a colostomy, chronic wounds, anxiety, and depression, was fully dependent on staff for care and was cognitively intact according to the most recent assessment. During early morning care, the resident reported that the CNA roughly grabbed and squeezed their left wrist, spoke in a rude and disrespectful manner, and laughed at the resident when asked for his name. The incident was reported by the resident to a nurse immediately after it occurred. The resident described that when they were unable to turn as requested by the CNA, the aide became upset, raised his voice, and continued to be rude. The resident also reported that the CNA responded to their request for his name by laughing and leaving the room. Multiple staff interviews confirmed that the resident consistently described the CNA's behavior as rough, rude, and disrespectful, and that the resident felt hurt and disrespected by the interaction. Facility records and staff interviews indicated that the resident's complaints were promptly reported and documented. The facility's internal investigation substantiated the resident's account of being treated in a manner that was not consistent with the facility's policy on resident rights, which requires all residents to be treated with kindness, respect, and dignity. The CNA involved denied being physically or verbally abusive but did acknowledge that the resident complained about rough care and that he apologized.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the appropriate competencies required to care for every resident in a manner that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked the necessary skills or knowledge to provide care tailored to the individual needs of residents. This failure resulted in care that did not fully support or enhance the well-being of all residents as required.
Failure to Provide Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of suicidal ideation (SI) and depression. The resident, who was admitted in February 2023, had a history of depression and dementia and was admitted after vocalizing passive SI. Despite recommendations for a psychiatric consult and medication recommendations, the facility did not implement a care plan for SI after the resident's return from the hospital in August 2023. The medical record lacked evidence of a referral for psychotherapy or an updated plan of care to address the resident's SI. The facility's failure to maintain the highest practicable physical, mental, and psychosocial well-being for the resident was evident when the resident attempted suicide by trying to jump over a second-floor balcony in December 2023. The incident was intervened by the Maintenance Director, and the resident was sent to the hospital. Upon readmission, the facility did not review or update the resident's plan of care, despite the recent suicide attempt. The medical record also failed to indicate that the Psych NP's recommended treatment plan was communicated to staff, implemented, or tracked. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's SI and suicide attempt. The facility's Social Worker was unaware of the resident's history of SI and suicide attempt, and the Nurse Unit Manager acknowledged that the resident should have been evaluated for talk therapy. The Psych NP stated that referrals for psych services were not made, and the resident's physician expected the resident to be followed closely by the facility's Social Worker. The Director of Nursing expressed surprise that the Social Worker was not informed of the resident's history and expected the resident to be assessed by psych services upon admission.
Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a known history of depression, suicidal ideation (SI), and adjustment difficulty. The resident, admitted in February 2023, had diagnoses including depression and dementia. Despite recommendations for a psychiatric consult and medication management upon admission, the facility did not develop or update a care plan addressing the resident's SI. This oversight persisted even after the resident expressed active suicidal ideation in August 2023, leading to hospitalization. Upon the resident's return from the hospital, the facility did not implement or update a care plan to monitor and manage the resident's SI. The resident continued to experience anxiety, sadness, and frustration, yet there was no referral for talk therapy or specific behavioral management interventions. The facility's failure to communicate and implement the Psych NP's recommended treatment plan further exemplified the lack of coordinated care. In December 2023, the resident attempted suicide at the facility, which was prevented by staff intervention. Despite this serious incident, the facility did not review or update the resident's care plan upon readmission. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's history and needs, highlighting systemic issues in managing residents with behavioral health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies in their care. For one resident, the facility did not create a care plan addressing suicidal ideation (SI) despite the resident's history and vocalization of SI. This oversight resulted in the resident attempting suicide at the facility. The facility's policy required timely intervention and continuous monitoring for residents with SI, but these measures were not implemented. The resident's care plan was not updated after multiple incidents of SI, and the facility staff, including the social worker and nurse unit manager, were unaware of the resident's history and recent suicide attempt. Another resident was admitted with a diagnosis of incontinence, but the facility failed to develop a care plan to address this condition. The resident was consistently incontinent and expressed dissatisfaction with the lack of timely incontinence care, particularly before meals. Despite the resident's repeated requests and the facility's policy to provide prompt incontinence care, the staff did not implement a care plan or provide the necessary interventions. The Director of Nursing and MDS Nurse acknowledged the oversight, noting that an incontinence care plan should have been developed based on the resident's assessment. The deficiencies in care planning for both residents highlight a failure to adhere to the facility's policies and procedures for developing and updating comprehensive care plans. The lack of communication and coordination among staff members contributed to the inadequate care provided to these residents, resulting in unmet medical and psychological needs.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to provide necessary treatment and interventions to prevent and manage pressure ulcers for a resident at high risk. The resident, who was cognitively intact and required assistance with mobility, had a history of pressure ulcers and was assessed to be at high risk for developing new ones. Despite physician orders to offload the resident's heels and maintain specific air mattress settings, these interventions were not consistently implemented. Observations revealed the resident's heels were not offloaded, and the air mattress was set incorrectly, leading to the reopening of a previously healed pressure ulcer on the left upper Achilles heel. Additionally, the facility did not obtain wound care orders for the newly developed pressure ulcer on the resident's left upper Achilles heel. The resident's medical record lacked any documentation of wound care orders for this area, and interviews with nursing staff confirmed that no treatment was in place for the pressure ulcer. The lack of communication and documentation regarding the resident's wound care needs contributed to the deficiency. The facility also failed to conduct and document weekly assessments and measurements of a deep tissue injury (DTI) on the resident's right heel. Despite the presence of the DTI since at least August, there were no recorded assessments or measurements in the past three months. Furthermore, weekly skin assessments were not consistently completed, with documentation missing for eight out of eleven weeks. These lapses in care and documentation highlight significant deficiencies in the facility's pressure ulcer prevention and management practices.
Deficiency in Nursing Staff Wound Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies in wound care, as outlined in the Facility Assessment. The surveyors identified multiple deficiencies during the recertification survey, including the failure to implement pressure ulcer prevention interventions, assess and measure wounds weekly, perform hand hygiene during wound care, obtain treatment orders for wounds, notify providers of new wounds, transcribe new wound care orders, and complete weekly skin checks. These deficiencies were linked to the lack of completed wound care competencies for the nursing staff. The review of staff education files revealed that none of the three licensed nurses with identified concerns had completed wound care competencies within the last year. The Director of Nursing acknowledged that the facility's policy required annual completion of these competencies, but there was a gap in staff development due to the absence of a staff development nurse from November 2023 to April 2024, and again from August 2024 to the present. This lack of training and competency assessment contributed to the deficiencies observed in wound care practices.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update the care plans or complete falls assessments for two residents after they experienced falls, resulting in deficiencies in care. Resident #38, who was admitted with diagnoses including depression and unsteadiness on feet, experienced multiple falls, including one that resulted in a fracture. Despite these incidents, the care plan for Resident #38 was not reviewed or revised to include new interventions to prevent further falls. The Director of Nursing indicated that the expectation was for the care plan to be updated after each fall, but this was not done. Resident #27, admitted with diagnoses including muscle weakness and difficulty walking, also experienced a fall that resulted in a fracture. The care plan for Resident #27 was not reviewed or revised following this incident. The Director of Nursing stated that the care plan should have been updated after the fall, but it was not. The facility's policy on fall reduction requires that falls be investigated and care plans updated with appropriate interventions, which was not adhered to in these cases. The facility's failure to update care plans and conduct falls assessments after incidents of falls for these residents indicates a lack of adherence to their own fall reduction policy. This oversight potentially contributed to the residents' injuries and highlights a deficiency in the facility's management of fall risks and care plan updates.
Failure to Ensure Proper Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring dialysis. The resident, who was cognitively intact and diagnosed with end-stage renal disease, reported that staff often forgot to send the dialysis communication book to the dialysis center. This book was essential for communication between the facility and the dialysis center. The resident's care plan required the communication book to be sent to each dialysis treatment, but the facility did not ensure this was done consistently. The review of the resident's dialysis communication book revealed that post-dialysis weights were not documented for 11 out of 14 scheduled treatments, and there was no follow-up on the missing information in the resident's medical record. Interviews with facility staff, including nurses, the nurse unit manager, the nurse practitioner, the dietitian, and the director of nursing, highlighted a lack of communication and collaboration with the dialysis center. Staff acknowledged the importance of obtaining post-dialysis weights to monitor for complications, but there was a misunderstanding about the facility's responsibility in managing the resident's dialysis care. The nurse unit manager believed the dialysis center was responsible for all aspects of the resident's care, while the nurse practitioner and dietitian emphasized the need for the facility to monitor post-dialysis weights. The director of nursing confirmed that staff should obtain and document weights if the dialysis communication sheet was incomplete.
Failure to Implement Physician Orders for Wound Care and Heel Protection
Penalty
Summary
The facility failed to ensure that services provided met professional standards for two residents. For one resident, the facility did not transcribe and implement a daily wound dressing according to the physician's order for ten days. The resident had a non-pressure wound on the right upper lateral buttock that required daily application of Xeroform gauze, tape, and an ABD pad. Observations revealed that the wound was not dressed, and interviews with staff confirmed that the dressing was not applied as ordered. The Nurse Unit Manager admitted to not transcribing the orders, and the Director of Nursing acknowledged that the orders should have been implemented. Additionally, the same resident had a physician's order to cleanse and dress bilateral lower extremities daily for venous stasis ulcers. However, observations showed that the dressing on the left lower extremity had not been changed for two days, and there was no dressing on the right lower extremity. The nurse confirmed that the dressing should have been changed daily and that there was no documentation of refusal by the resident. For another resident, the facility failed to implement physician orders for heel protection booties. The resident was observed in bed without the booties on multiple occasions, despite orders to apply them while in bed. The Nurse Unit Manager stated that staff should follow the physician's orders and document any refusal by the resident, but the clinical record did not indicate any refusal. This lack of documentation and implementation of orders highlights a deficiency in the facility's adherence to professional standards of care.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide adequate Activity of Daily Living (ADL) care, specifically weekly showers, to three residents, as observed and reported during a resident group meeting. Six out of ten residents expressed concerns about not receiving weekly showers, with three residents being particularly vocal about their unmet needs. Resident #44, admitted with acute respiratory failure, was cognitively intact and dependent on staff for showering. Despite being scheduled for weekly showers, documentation showed that Resident #44 received only one shower in three months, with no records of refusal documented. Resident #14, admitted with chronic respiratory failure, also required substantial assistance for bathing. Despite being scheduled for weekly showers, Resident #14 reported not having had a shower in a long time, and documentation confirmed no showers were provided in the past three months. The care plan for Resident #14 did not address shower needs or the level of assistance required, and there was no documentation of shower refusals. Resident #54, with cerebral palsy and muscle weakness, was dependent on staff for ADLs and reported not having a shower in two years. Observations noted unwashed hair, and documentation indicated only one shower in the past two months, despite being scheduled for twice-weekly showers. The Director of Nursing acknowledged awareness of the issue but believed it had been resolved, yet no refusals were documented in the medical records for any of the residents.
Delay in Hearing Aid Process Due to Untimely Ear Wax Removal
Penalty
Summary
The facility failed to ensure timely implementation of services to maintain hearing for a resident, resulting in a delay in obtaining hearing aids. The resident, admitted in February 2022, had diagnoses including essential tremor, epilepsy, and cognitive communication deficit. Despite having intact cognition and minimal difficulty hearing, the resident had been requesting hearing aids for over a year. An audiologist recommended ear wax removal in December 2024, but the treatment was not implemented until September 2024, nearly nine months later. Interviews with staff revealed that the facility's process for obtaining orders for ear wax removal was not followed promptly. The Director of Nursing acknowledged that orders should be obtained the same day or shortly after a recommendation is made. However, the resident's medical records showed no order for ear wax removal until September 2024, despite a request for an audiology consult being made in April 2024. This delay in treatment led to a significant postponement in the process of obtaining hearing aids for the resident.
Failure to Provide Timely Incontinence Care Before Meals
Penalty
Summary
The facility failed to provide a dignified existence for a resident by not addressing their incontinence care needs before meals. The resident, who was cognitively intact and always incontinent of bowel and bladder, repeatedly had to eat breakfast while sitting in a soiled brief. This occurred on multiple days during the survey, and the resident expressed distress over the situation, stating that they had informed staff of their need for incontinence care before meals, but were told that assistance could not be provided during mealtime. The facility's policy on dignity and quality of life, which prohibits demeaning practices and requires prompt response to toileting assistance requests, was not adhered to. Despite the resident's repeated requests and the Director of Nursing's awareness of the issue, the staff failed to provide the necessary care. The resident's medical record also lacked a care plan for incontinence, further contributing to the deficiency.
Failure to Notify Physician and Obtain Wound Care Orders
Penalty
Summary
The facility failed to notify the physician and obtain wound treatment orders for two residents, leading to deficiencies in care. Resident #4, who was admitted with end-stage renal disease and diabetes, had a newly re-developed unstageable pressure ulcer on the left upper Achilles heel and a skin tear on the left hand. Despite the facility's policy requiring significant abnormal findings to be reported to the physician, the provider was not notified, and no wound care orders were obtained for these conditions. Interviews with staff revealed that the pressure ulcer had been present for at least two weeks without treatment, and the dressing on the resident's hand was applied without a physician's order. Resident #269, admitted with diabetes and a right arm fracture, had pressure wounds on the buttocks upon admission. The facility's assessments noted the presence of these wounds, yet the provider was not informed, and no wound care orders were obtained. Observations showed discoloration in the buttocks and perianal area, which staff were unsure how to classify. Despite the facility's policy, the physician was not notified of the skin condition, and no treatment orders were in place. The Director of Nursing acknowledged that the provider should have been notified for both residents to obtain appropriate wound care orders. The failure to communicate these significant changes in the residents' conditions to the physician resulted in a lack of necessary treatment, contrary to the facility's protocols.
Failure to Address Resident Grievances Regarding Staff Sleeping on Duty
Penalty
Summary
The facility failed to address grievances raised by a resident, identified as Resident #31, regarding staff behavior, specifically staff sleeping during night shifts. Despite the resident's repeated complaints to various staff members, including the Director of Nursing (DON) and a social worker, the facility did not follow its grievance policy. The policy requires grievances to be documented and investigated, with a resolution reported to the Administrator within five days. However, no grievances were recorded in the Grievance Log concerning Resident #31's complaints, and the issue persisted over a year. Resident #31, who was cognitively intact, expressed concerns about staff sleeping on duty multiple times, even providing photographic evidence to the administration. Despite these efforts, the resident felt that the complaints were not resolved, as the staff member in question continued to be employed and observed sleeping. During a resident group interview, other residents corroborated the issue, reporting similar observations of staff sleeping during night shifts, which affected the response to call lights. Interviews with staff, including CNAs and nurses, revealed that grievance forms were not consistently completed or filed, and the DON acknowledged awareness of the issue but could not provide documentation of any grievance forms or investigations related to the complaints.
Failure to Implement Abuse Policy for Resident
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident who was admitted with diagnoses including depression and unsteadiness on feet. The resident, who had severe cognitive impairment and required substantial to maximal assistance with transfers, was involved in an incident where a staff member alleged physical abuse by another nurse during an incorrect transfer. The facility's policy mandates that allegations of abuse be promptly reported and thoroughly investigated, with the Administrator and Director of Nursing responsible for implementing corrective actions and measures to prevent recurrence. Despite the facility's policy, the corrective measures following the abuse allegation, which included updating the resident's care plan and follow-up from the Social Worker, were not implemented. The clinical record did not show any updates to the care plan or any assessment by the Social Worker after the incident. During an interview, the Director of Nursing admitted to not updating the care plan and was unsure if the Social Worker had conducted a follow-up, which was not documented in the Social Worker's notes.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility failed to investigate allegations of neglect for two discharged residents. The first resident, who was cognitively intact and dependent on staff for toileting tasks, reported an incident where a CNA told them they would be changed later, resulting in a grievance that was not properly addressed. The grievance form's action taken section was left blank, and the summary of findings concluded it was a miscommunication without a thorough investigation. The second resident, also cognitively intact and requiring substantial assistance, reported being left in a chair for nine hours despite multiple requests to be put back to bed. The grievance form indicated that CNAs were spoken to about expectations, but no formal investigation was documented. The Director of Nursing acknowledged these grievances but did not provide any investigation documentation, viewing them as customer service issues rather than neglect.
Failure to Address Pharmacy Recommendations for a Resident
Penalty
Summary
The facility failed to review and address pharmacy recommendations for a resident with severe cognitive impairment and diagnoses including depression and unsteadiness on feet. The resident was admitted in August 2022, and the most recent Minimum Data Set (MDS) assessment indicated a need for substantial to maximal assistance with transfers. A pharmacist's note from September 2024 recommended evaluating the continued need for Enoxaparin and adding a stop date, as well as changing the timing of Atorvastatin administration. These recommendations were repeated in October 2024. However, the physician's orders did not reflect that these recommendations were reviewed or implemented. The Nurse Unit Manager acknowledged that the recommendations were not communicated to the physician due to her absence in September, and they were only signed by the physician a few days before the interview on October 31, 2024.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.45% error rate observed during a medication pass. Nurse #3 made two errors out of 31 opportunities while administering medications to a resident. Specifically, Nurse #3 administered the incorrect type of calcium carbonate without the required vitamin D and minerals and did not clarify the missing dosage. Additionally, Nurse #3 administered ferrous sulfate without clarifying the missing dosage, contrary to the facility's policy that requires medications to be administered in accordance with prescriber orders and verified three times for the correct dosage. The resident involved was admitted with diagnoses including diabetes and hypertension and had severe cognitive impairment. During the medication pass, Nurse #3 was unaware of the need to clarify the orders for the medications that lacked dosage information. Interviews with the Nurse Unit Manager and the Director of Nursing confirmed that the orders should have been clarified before administration, and the correct type of calcium carbonate was not available in the facility. This oversight led to the administration of incorrect medications to the resident.
Improper Storage of Medications in Unlabeled Containers
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws, specifically by not keeping medications in their original, labeled containers. During an observation, a surveyor and a nurse found two uncovered medication cups with unlabeled pills in a medication cart on the 2nd floor back hallway. One cup contained two white pills, while the other contained two white pills and one blue pill. Nurse #2 admitted to pouring the medications a few hours earlier but had not administered them because the residents were unavailable. She acknowledged that the medications should have been discarded at that time but intended to administer them later. The Director of Nursing confirmed that pills should not be stored in medication cups in the cart and should be discarded if a resident is unavailable or refuses them.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care. For one resident with diabetes and venous ulcers, the nurses documented a physician's order for wound care as implemented when it was not. The resident's treatment administration record indicated that the wound care was documented as completed on specific dates, but observations and interviews revealed that the dressings were not changed as ordered. The nurse confirmed that the dressing on the resident's left calf had not been changed for two days, and there was no documentation of refusal or rationale for not implementing the treatment. Additionally, the facility failed to complete daily documentation for three residents regarding their bathing and showering tasks. One resident, who was cognitively intact and required substantial assistance, had bathing documentation completed for only a few shifts out of many possible shifts over three months. Interviews with a CNA and the Director of Nursing confirmed that all care provided should be documented on all shifts, and there was significant missing documentation. Two other residents also experienced similar issues with incomplete documentation of bathing tasks. One resident with moderate cognitive impairment and another who was cognitively intact and dependent on staff for bathing had documentation completed for only a fraction of the possible shifts over the same three-month period. The Director of Nursing acknowledged the missing documentation and stated that all care should be documented on all shifts.
Failure to Address Resident Shower Concerns in QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan addressing residents' concerns about not receiving showers. The deficiency was identified through a review of Resident Council minutes from multiple meetings, where residents consistently reported that scheduled showers were not being provided. During a Resident Group meeting, a majority of participants expressed that they had not had a shower in a long time and did not feel clean. An interview with the Director of Nursing revealed that the issue had not been brought to the QAPI process because the Activities Director, responsible for running the resident council meetings, had not been sharing the minutes with her. Consequently, the Director of Nursing was unaware of the ongoing issue with showers not being provided.
Inadequate Hand Hygiene During Wound and Tracheotomy Care
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by two specific incidents involving a nurse's inadequate hand hygiene practices. In the first incident, a nurse was observed performing wound care on a resident without adhering to proper hand hygiene protocols. The nurse removed soiled gloves and applied new ones multiple times without performing hand hygiene in between, despite the facility's policy requiring hand hygiene after glove removal. This lapse occurred during the care of both a lower leg wound and a surgical abdominal wound, and the nurse acknowledged the oversight during an interview. In the second incident, the same nurse was observed providing tracheotomy care without following appropriate hand hygiene procedures. After cleansing the tracheotomy tube and handling secretions, the nurse failed to change gloves and perform hand hygiene before applying new, clean tracheotomy ties. This action was contrary to the facility's policy, which mandates glove removal and hand hygiene after contact with body fluids. The nurse admitted to being unaware of the need to change gloves and perform hand hygiene in this context, and the Director of Nursing confirmed the correct procedure during an interview.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor the residents' rights to receive written notice before a room change or the introduction of a new roommate. This deficiency affected 21 residents who were alert, oriented, and able to communicate with staff. The facility's policy, revised on December 6, 2021, required that residents be informed verbally and in writing of any room changes or new roommates. However, during the review of clinical records and interviews, it was found that no written notices were provided to the affected residents prior to the changes. The deficiency was identified through a review of the facility's daily census reports and clinical records, which showed multiple room changes and new roommate assignments on August 28 and 29, 2024. Interviews with 15 affected residents confirmed that they did not receive written notice of these changes. Additionally, a representative for one resident reported not receiving any notice prior to the room change. The Medical Records Coordinator confirmed the absence of written notices in the medical records for the sampled residents. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that a corporate directive prompted the immediate relocation of residents from the Short Term Rehabilitation (STR) Unit to the Long Term Care (LTC) Unit. The Administrator and DON acknowledged that the moves could have been postponed to comply with the facility's policy, which required at least 24 hours' notice. They admitted that residents were not shown their new rooms or introduced to their new roommates, and that the affected residents did not have the opportunity to discuss the changes with their families or representatives.
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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 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.
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.
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.
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.
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 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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