Odd Fellows Home Of Massachusetts
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 104 Randolph Road, Worcester, Massachusetts 01606
- CMS Provider Number
- 225439
- Inspections on file
- 19
- Latest survey
- December 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Odd Fellows Home Of Massachusetts during CMS and state inspections, most recent first.
The facility failed to implement safety measures for three residents, including not following safe swallow strategies for a resident with swallowing difficulties and not completing fall risk assessments for two residents after hospitalization. Staff were not adequately informed or trained, leading to increased risk of accidents and injuries.
A resident with dementia and dysphagia did not receive routine dental services despite signing a consent form in 2020. The facility failed to schedule dental appointments, resulting in dental deterioration. The resident was observed with missing and broken teeth, and a dentist later found poor dentition and gingivitis. The Unit Manager confirmed the oversight, and the Director of Nursing acknowledged the expectation for timely dental care.
A resident with dementia was found using a dusty and debris-laden wheelchair, which had not been cleaned since their admission. Despite requests from the resident and their family, the facility lacked a tracking system and policy for wheelchair cleaning, as acknowledged by the Housekeeping Manager and Administrator.
A facility failed to accurately complete a Level I PASRR for a resident with Schizophrenia, resulting in the resident not receiving a necessary Level II PASRR Evaluation. The resident had a court-appointed legal guardian and was on antipsychotic medication, but these factors were not properly documented, leading to a negative SMI screen and no referral for further evaluation.
Two residents in a facility experienced deficiencies in care. One resident's swallowing ability was not assessed in a timely manner, despite a decline in function and weight loss, leading to a delayed speech therapy evaluation. Another resident had an incorrect size urinary catheter in place, contrary to physician orders, which could lead to complications. These issues highlight lapses in communication and adherence to care plans.
A resident with dementia and muscle weakness was not properly assessed or treated for finger contractures, as required by facility policy. Despite a PA noting the contractures, no follow-up or monitoring was documented, and staff were unaware of the issue until a surveyor's observation. The DON acknowledged the need for a rehab screen and monitoring, which were not conducted, leading to unaddressed contractures.
The facility failed to maintain accurate medical records for three residents, including incomplete documentation of urinary output and missing speech therapy evaluations. A resident with a urinary catheter had vague and missing entries for urine output, while another resident's intake and output records were incomplete and unclear. Additionally, a resident's speech therapy documentation was not included in the electronic health record, leaving staff unaware of recommended safe swallowing strategies.
A facility failed to adhere to infection control standards for a resident with an indwelling urinary catheter. Staff transferred the resident without wearing protective gowns, contrary to the facility's Enhanced Barrier Precautions (EBP) policy, which requires gowns and gloves during high-contact care activities. Despite EBP signage indicating the need for such precautions, staff did not comply, as confirmed by interviews with the CNA and the SDC/IP.
A facility failed to inspect bed rails for entrapment risk for a resident with limited mobility using bilateral side rails. Despite policies requiring assessments to prevent entrapment, the Maintenance Director could not provide evidence of such assessments for the resident's bed and mattress. The resident, with conditions like Vascular Dementia and muscle weakness, was observed bed-bound with side rails in place, highlighting a lapse in following safety procedures.
The facility failed to issue SNF ABN notices to three residents when their Medicare Part A benefits ended, leaving them uninformed about potential financial liabilities. The residents, with various medical conditions, chose to remain in the facility without receiving the required notices. The Social Worker confirmed the oversight in issuing these notices.
The facility failed to ensure the Medical Director's attendance at two out of four required quarterly QAPI meetings. The facility's QAPI Plan mandates the Medical Director's presence at least quarterly. The Medical Director attended meetings in April and October but missed those in January and July, as confirmed by the Administrator.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to provide an environment as free of accident hazards as possible for three residents. For one resident with a history of swallowing difficulty and dementia, the facility did not implement safe swallow strategies. Despite being on a downgraded diet due to coughing concerns, the resident was observed alone with food in their mouth, indicating a lack of supervision and adherence to recommended swallowing precautions. Interviews revealed that staff were not adequately informed or educated about the resident's swallowing strategies, and there was a lack of communication between the speech-language pathologist and the care team. Two other residents, both with a history of falls and on anticoagulant medication, were not reassessed for fall risk upon readmission to the facility after hospitalization. One resident had been hospitalized due to a fall resulting in a fracture and surgery, while the other had a fall at home leading to a spinal fracture. Despite these incidents, the facility did not complete fall risk assessments upon their return, which was against the facility's policy. Interviews with staff confirmed the oversight, and there was no evidence of post-hospitalization fall risk assessments in the residents' medical records. The lack of proper assessments and communication regarding the residents' conditions and care needs led to an increased risk of accidents and injuries. The facility's failure to adhere to its policies and ensure staff were informed and trained on necessary precautions contributed to the deficiencies observed by the surveyors.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, resulting in complications related to dental deterioration. The resident, who was admitted in January 2020 with diagnoses including dementia and dysphagia, had signed a dental consent form in January 2020 indicating a desire to receive dental care. Despite this, the facility did not schedule any dental appointments for the resident, and there was no record of the resident receiving any dental services as requested. The resident was observed to have several missing and broken teeth, and a review of the medical record indicated a physician order for a dentist consult as needed, which was not acted upon. The deficiency was further highlighted during interviews with the Unit Manager (UM) and the Director of Nursing (DON). The UM confirmed that the resident had never been seen by the dentist since signing the consent and was not on the list to be seen. It was only after the surveyor's inquiry that the resident was seen by a dentist, who found very poor dentition, fractured teeth, multiple roots, poor oral hygiene, and moderate to severe gingivitis. The DON stated that the expectation was for residents to receive dental services as soon as possible after signing a consent form, which did not occur in this case.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was admitted with dementia. The resident, who was mildly cognitively impaired, was observed using a wheelchair that was dusty and had crumbs and debris on the frame and cushion. The resident expressed concern about the cleanliness of the wheelchair, stating it had not been cleaned since they began using it. A family member also reported having requested the wheelchair be cleaned multiple times without success. The Housekeeping Manager acknowledged the lack of a tracking log for wheelchair cleaning and admitted there was no evidence of when the resident's wheelchair was last cleaned. The manager observed the wheelchair's condition and deemed it unacceptable. The facility administrator confirmed the absence of a policy regarding wheelchair cleaning, indicating a gap in the facility's procedures for maintaining a clean environment.
Failure to Complete Accurate PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete a Level I PASRR for a resident, which resulted in the resident not receiving a necessary Level II PASRR Evaluation. The resident was admitted with a diagnosis of Schizophrenia, and the hospital records indicated a history of worsening dementia, hallucinations, and violent behavior. Despite this, the Level I PASRR did not document the resident's mental illness or disorder, leading to a negative SMI screen and no referral for a Level II evaluation. Additionally, the resident had a court-appointed legal guardian within two years prior to admission, which was not accurately reflected in the PASRR documentation. The social worker acknowledged that the presence of a legal guardian should have indicated legal involvement, necessitating a positive SMI screen and a referral for further evaluation. The oversight in the PASRR process meant that the resident's need for specialized services for serious mental illness was not assessed as required.
Failure to Timely Assess Swallowing and Incorrect Catheter Use
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents. For Resident #83, the facility did not assess the resident's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP). The resident, who was admitted with diagnoses including dementia and muscle weakness, experienced a decline in swallowing function and weight loss, necessitating a diet texture downgrade. Despite the NP's order for a speech therapy evaluation on 10/25/24, the referral was not completed until 11/21/24, resulting in a delayed assessment by the Speech Language Pathologist (SLP) on 11/27/24. This delay in evaluation and treatment potentially impacted the resident's nutritional status and overall health. Resident #37 was found to have an incorrect size indwelling urinary catheter in place, contrary to the physician's orders. The resident, admitted with unspecified neuromuscular dysfunction of the bladder, had a physician's order for a 16 French/10 ml balloon Foley catheter. However, during an observation, it was noted that an 18 French/30 ml balloon Foley catheter was in use. This discrepancy was acknowledged by the nursing staff, who confirmed that the correct size catheter was available in the central supply room but had not been utilized. The use of an incorrect catheter size could lead to complications, as noted by the facility's staff educator and Director of Nursing (DON). The deficiencies highlight lapses in communication and adherence to physician orders within the facility. In the case of Resident #83, the delay in referral for speech therapy evaluation was attributed to a lack of awareness by the Director of Rehabilitation (DOR) and the interdisciplinary team (IDT) until several weeks after the initial order. For Resident #37, the failure to use the correct catheter size was a result of not following established physician orders, despite the availability of the correct supplies. These issues underscore the importance of timely and accurate execution of care plans to ensure resident safety and well-being.
Failure to Address Resident's Finger Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with contractures, specifically neglecting to assess, monitor, and treat the resident's right third and fourth finger mild contractures. The resident, admitted in January 2020 with diagnoses including dementia and generalized muscle weakness, was observed by a surveyor with contracted fingers and no positioning device or splint in place. The resident reported no pain and stated that staff did not provide any range of motion (ROM) exercises, and was unable to open their hand upon request. The facility's policy required residents with limited ROM to receive treatment and services to prevent further decline, but the resident's medical record showed no follow-up or reference to the contractures after a Physician Assistant (PA) noted them in September 2024. The PA had expected nursing staff to monitor for pain, skin integrity issues, and decreased function or ROM, but there was no evidence of such monitoring or intervention in the resident's medical record. The Unit Manager and Director of Rehabilitation were unaware of the contractures until pointed out by the surveyor. The Director of Nursing acknowledged that a rehab screen should have been performed when the contractures were identified, and nursing staff should have monitored and assessed the resident's condition. The lack of timely assessment and intervention led to the resident's contractures being unaddressed, potentially worsening over time without appropriate therapeutic measures in place.
Inaccurate Documentation of Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documenting urinary output and speech therapy evaluations. Resident #46, who had a urinary catheter, did not have accurate measurements of urinary output documented as ordered. Instead, urine output was recorded in vague terms such as 'medium' or 'large' on several dates, and there were instances where no output was recorded at all. The Director of Nursing (DON) acknowledged the confusion surrounding the physician's order for intake and output monitoring and expressed a need to revise the process. Resident #69, who also had an indwelling urinary catheter, had incomplete and inaccurate documentation of 24-hour fluid intake and urinary output. The Treatment Administration Record (TAR) showed missing entries and unclear notations, such as the use of a '+' sign, which the DON could not interpret. The DON confirmed that the intake and output monitoring was not recorded accurately in the resident's clinical record. Resident #83's clinical record lacked documentation of speech therapy evaluations, treatment notes, and discharge summaries. Although the resident had been evaluated and treated by a Speech Language Pathologist (SLP), the documentation was not included in the electronic health record (EHR) accessible to facility staff. The Director of Rehabilitation (DOR) admitted that the electronic submissions were supposed to transfer automatically into the EHR but did not, leaving the staff unaware of the safe swallowing strategies recommended for the resident.
Failure to Follow Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to adhere to infection control standards for a resident with an indwelling urinary catheter, identified as Resident #69. The deficiency was observed when two staff members transferred the resident from bed to a wheelchair without wearing protective gowns, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices to prevent the transmission of multi-drug-resistant organisms. Despite the presence of EBP signage outside the resident's room, indicating the need for gowns and gloves during such activities, the staff did not comply with these precautions. Resident #69, who was admitted to the facility with diagnoses including obstructive and reflux uropathy, urinary tract infection, and urethral fistula, was severely cognitively impaired and had an indwelling urinary catheter. The staff's failure to follow EBP was confirmed through interviews with the Certified Nurses Aide (CNA) involved and the Staff Development Coordinator/Infection Preventionist (SDC/IP). The CNA believed that only hand sanitization and glove use were necessary when handling the resident's Foley catheter, while the SDC/IP confirmed that EBP should be followed for any high-contact care involving residents with indwelling medical devices, such as transferring and handling bed linens.
Failure to Assess Bed Rails for Entrapment Risk
Penalty
Summary
The facility failed to complete an inspection of the bed rails to identify areas of possible entrapment for a resident with limited mobility who utilized bilateral side rails. The facility's policy required assessments to determine the risk of entrapment and to ensure the safe use of side rails and mattresses. However, the Maintenance Director was unable to provide evidence of any past assessments for the resident's current bed and mattress, indicating a lapse in following the facility's procedures. The resident, admitted in July 2020, had diagnoses including Vascular Dementia, Polyneuropathy, and muscle weakness, and was dependent on staff for various activities of daily living. Observations by the surveyor noted the resident lying in bed with bilateral side rails in place, and the resident confirmed being bed-bound. Despite the facility's policy requiring specific measurements to rule out entrapment risks, no documentation was available to confirm that these assessments had been conducted for the resident's bed setup.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN) to three residents when they no longer qualified for Medicare Part A skilled services. This deficiency was identified for three residents who chose to remain in the facility after their Medicare benefits ended. The facility did not provide the necessary SNF ABN notices, which are required to inform residents of their potential financial liability for services that may not be covered by Medicare. Resident #17, admitted with diagnoses including hypertension, depression, and hyperlipidemia, had their Medicare Part A benefits end without receiving an SNF ABN. Similarly, Resident #35, diagnosed with diabetes mellitus, and Resident #38, with anemia, coronary artery disease, and heart failure, also did not receive the required notices when their Medicare benefits ended. The Social Worker acknowledged that the SNF ABN forms were not issued for these residents, indicating a lapse in the facility's process for notifying residents of their financial responsibilities.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the Medical Director did not attend two out of the four required quarterly QAPI meetings. According to the facility's QAPI Plan dated January 16, 2019, the Medical Director is required to attend these meetings at least quarterly, with a preference for monthly attendance. During a review of the QAPI meeting schedule and attendance sheets, it was found that the Medical Director attended the meetings in April and October 2024 but did not attend or sign the attendance sheets for the meetings in January and July 2024. The Administrator confirmed that the Medical Director should have attended these meetings as required.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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