Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Odd Fellows Home Of Massachusetts during CMS and state inspections, most recent first.
Failure to Arrange Dental Care After Resident Consent: Three residents with signed dental consents were not assisted in obtaining routine dental services. One resident with DM, HTN, and GERD had tooth pain, an NP referral, and a later dental visit that was blocked by expired insurance, but the record did not show routine dental follow-up. Another resident with dementia and DM requested dental services and dentures but was not placed on the vendor list. A third resident with dysphagia and pulmonary HTN also requested dental care and dentures, but the consent was not followed when the dental vendor was in the facility.
Infection Control Precautions Not Followed: Staff did not follow ordered Contact Precautions for a resident with suspected scabies, entering the room and handling items without hand hygiene or PPE. A second resident with symptomatic C. diff was managed under EBP signage instead of Contact Precautions, and staff entered the room without gown and gloves while the resident was still being treated. For a third resident on EBP for high-contact care, staff transferred the resident and handled linens without the required gown and hand hygiene.
Two residents had rooms that were not maintained in a clean, sanitary, and homelike condition. One resident with severe cognitive impairment and a Foley catheter had repeated leakage and large dried urine stains on the bedroom floor for weeks. Another resident with dementia and total ADL dependence had a strong fecal odor and dried brown stains on the bed frame, bed rail, mattress, floor, and floor mat; the DON/Administrator observed the conditions and acknowledged the rooms were not home-like.
A resident with DM, bilateral cataracts, and blindness in one eye consented to vision services and requested an eye exam and updated eyeglasses, but the facility did not schedule the resident for the optometry vendor visit or provide evidence that the resident was placed on the next routine list. The Administrator and DON stated the resident should have been added after consent, yet the resident remained waiting for evaluation despite severely impaired vision and an order for optometry consult as needed.
Failure to Document and Administer Ordered Oxygen Therapy: A resident with COPD and oxygen dependence had incomplete O2 orders that did not include a baseline flow rate or portable flow rate, and MAR/TAR documentation did not show the oxygen flow rate being administered. Surveyors observed the resident in a wheelchair with NC tubing not connected to the portable concentrator, and staff later confirmed the resident used O2 at 2 LPM and that a respiratory assessment should have been documented when oxygen was given.
Failure to Offer Pneumococcal Vaccination: A resident with COPD and supplemental O2 dependence had no record of prior pneumococcal immunization, and the chart did not show the vaccine was offered, declined, or contraindicated. The MDS indicated the vaccine was not up to date and had not been offered, and the IP confirmed the HCP was not contacted for consent.
Failure to Offer COVID-19 Vaccine to a High-Risk Resident: A resident with COPD and dependence on supplemental O2 had an out-of-date COVID-19 vaccination status, with no record that the 2025-2026 Spikevax vaccine was offered, declined, or contraindicated. The IP confirmed the resident’s HCP should have been contacted for consent, and the resident was identified as being at high risk for COVID-19 complications due to COPD.
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 Arrange Dental Care After Resident Consent
Penalty
Summary
The facility failed to assist three residents with signed consents in obtaining routine dental care. The report states that the facility’s Dental Services Policy required residents to be assisted in obtaining regular and emergency dental care through the dentist or dental service indicated at admission, and that each resident may have an annual oral examination recorded in the resident’s record. Surveyors identified that Residents #30, #62, and #88 had consented to dental services, but the facility did not ensure they were placed on the dental vendor list or otherwise scheduled for dental care as described in the record. Resident #30 was admitted with diagnoses including diabetes, hypertension, and GERD. The resident had signed consent for dental care and later complained of tooth pain, prompting an NP assessment, antibiotic treatment, and a referral to a dentist. The record showed the resident went to the dentist on one occasion because of tooth pain, but the dentist did not see the resident because the insurance had expired. The clinical record did not show evidence that the facility assisted the resident in obtaining routine dental care between the date of consent and the later dental visit, and it also did not show evidence of assistance after insurance eligibility was restored. During interview, the resident said he/she had not been seen for an oral cavity inspection or teeth cleaning in over a year and wanted to see a dentist; the surveyor observed brown discoloration on the front top teeth. Resident #62 was admitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, vitamin deficiencies, and hypertension. The resident wore full upper and lower dentures, had a dental consult order as needed, and the dental services contract showed the resident requested dental services. The resident stated he/she had no natural teeth or dentures and wanted an oral exam, but had not been given an appointment date or time. The Administrator and DON acknowledged that residents who consent for dental services are supposed to be placed on the vendor list, but the facility could not provide evidence that Resident #62 was currently on the list or had been scheduled. Resident #88, who was cognitively intact and had diagnoses including dysphagia, pulmonary hypertension, and anemia, also had a signed request for dental services. The resident said he/she had not seen a dentist since being in the facility and wanted to be evaluated for dentures. The Administrator stated that the resident’s consent forms were not followed when the dental vendor was in the facility and that the resident was not placed on the list for evaluation for dentures until the surveyor brought it to the facility’s attention.
Infection Control Precautions Not Followed
Penalty
Summary
The facility failed to implement infection control practices for three residents with different precautions in place. For a resident with suspected scabies, the care plan directed staff to maintain Contact Precautions at all times, and the room had signage instructing staff to don gloves and a gown on entry and remove them before leaving. During observation, housekeeping staff entered the room carrying clothing, placed items in the dresser and closet, and exited without hand hygiene or PPE. A CNA also entered the room without hand hygiene or PPE, touched the privacy curtain and bed linens, and left without performing hand hygiene. The Infection Preventionist stated the resident still had a rash on the thighs and that Contact Precautions should continue until dermatology cleared the suspected scabies infection. For a second resident with symptomatic C. diff, the record showed diarrhea, a stool test ordered, positive lab results, and treatment with vancomycin. The physician orders did not indicate Contact Precautions for active C. diff treatment, and the door initially displayed only Enhanced Barrier Precautions signage. The EBP sign instructed staff to clean hands and wear gown and gloves only for high-contact care activities. The Infection Preventionist stated the resident was symptomatic for C. diff and required Contact Precautions, and also stated the EBP sign did not match the requirements for Contact Precautions because staff were required to wash hands with soap and water when exiting and wear gown and gloves when entering the room. A nurse stated she entered the room to administer medications without gown and gloves while the EBP sign was posted, and the Infection Preventionist later stated the resident’s C. diff infection had not actually resolved. For a third resident with an indwelling urinary catheter and a stage 3 pressure ulcer, the physician orders required Enhanced Barrier Precautions during high-contact care, including bathing, dressing, transferring, linen changes, hygiene, device management, and wound care. The room had EBP signage listing those activities. During observation, a CNA exited the room with a hydraulic lift without hand hygiene or PPE, another CNA handled linens while wearing gloves but no gown, and then re-entered the room to reposition the blanket without hand hygiene or PPE. In interviews, the CNAs stated they should have worn a gown during the transfer and while handling linens. The Infection Preventionist stated nursing staff should have worn a gown when transferring the resident.
Unclean Resident Rooms and Soiled Surfaces
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents on the Second Floor-South unit. Resident #52, who was admitted with benign prostatic hyperplasia and obstructive and reflux uropathy, had severe cognitive impairment, required substantial to maximal assistance with toileting, and had an indwelling Foley catheter. The resident’s progress notes showed repeated catheter changes for leakage, and surveyors observed three large, dried, bright yellow/orange stains on the bedroom floor on multiple observations. The resident stated that the catheter frequently leaked and that the stains had been on the floor for weeks. The Administrator later observed the stains and said the resident’s bedroom environment was not home-like. Resident #70, who had dementia, lack of coordination, and unsteadiness on feet, was severely cognitively impaired, dependent on staff for ADLs, and always incontinent of urine and bowel. Surveyors observed a strong odor of feces in the room and dried, dark brown stains on the bed frame, bed rail, mattress, tile floor, and floor mat on repeated observations. The stains remained present when the surveyor and Administrator observed the room together, and the Administrator stated that the stains were an infection control concern and that the room was not a home-like environment.
Failure to Coordinate Vision Services for a Resident with Severe Visual Impairment
Penalty
Summary
The facility failed to coordinate vision care services for a resident with Type 2 diabetes, bilateral cataracts, and blindness in the left eye. The resident was admitted in February 2026 with diagnoses including age-related nuclear cataract in both eyes, essential hypertension, and blindness in the left eye. The resident’s admission record noted an unreactive left pupil due to a left eye problem, and the March 2026 MDS indicated severely impaired vision and use of corrective lenses. The resident signed a request for eye care services on 2/2/26 and consented to vision services upon admission. The physician’s orders included an optometrist consult as needed. During observation and interview, the resident stated a desire to see the eye doctor for an exam, reported being blind in the left eye, and said it was difficult to see with the left eye and that eyeglasses needed to be replaced with a different prescription strength to meet visual needs. The resident also stated that an eye examination had not yet been scheduled despite the request for services. The facility’s Administrator stated that vision services were provided through an outside vendor every four months and as needed, and that the resident should have been placed on the next scheduled list because the resident had consented and had medical conditions requiring earlier evaluation. The Administrator said the resident was not on the list for routine vision care. The DON stated nursing staff were responsible for ensuring the resident was added to the vendor list for the next visit if the resident had consented, but no evidence was provided that the resident had been placed on the next scheduled vision services list.
Failure to Document and Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident with COPD and dependence on supplemental oxygen. The resident was admitted with diagnoses including COPD, dependence on supplemental oxygen, and diastolic congestive heart failure. The facility’s policy stated that a practitioner’s order is required to initiate oxygen therapy and that the order should include the oxygen flow rate and a titration range to achieve an acceptable SpO2 range. Resident #88’s physician orders included oxygen via nasal cannula to maintain oxygen above 90% as needed, but the orders did not include a baseline oxygen flow rate or portable oxygen flow rate. The February and March 2026 MAR/TAR did not document the oxygen flow rate being administered, although nursing progress notes documented oxygen at 2 LPM via nasal cannula. The resident’s admission/readmission assessment also indicated respiratory status as oxygen at 2 liters, and the care plan directed use of oxygen via nasal cannula or mask to maintain oxygen saturation above 90% as needed. During observation, the resident was seen with oxygen tubing hanging on the side of the wheelchair and not connected to the portable oxygen concentrator, while the resident stated he/she did not feel oxygen was being received through the nasal cannula. Nurse #3 then connected the tubing to the concentrator. Later observations showed the resident using oxygen at 2 LPM via nasal cannula, and staff interviews confirmed the resident used portable and bedside oxygen daily and continuously at night. Nurse #3 and the DON stated the physician’s orders should have included the oxygen flow rate and that a respiratory assessment should have been documented when oxygen was administered, but this was not done.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer pneumococcal immunization to one resident who was reviewed for pneumococcal vaccination status. The resident had a diagnosis of COPD and dependence on supplemental oxygen, had no evidence of prior pneumococcal immunizations in the medical record, and there was no documentation that the vaccine had been identified as medically contraindicated. The resident’s MDS indicated that the pneumococcal vaccination was not up to date and had not been offered. Review of the medical record found no documentation that pneumococcal vaccination had been offered, declined, or contraindicated. The resident had an invoked HCP in place, but the record did not show that the HCP had been contacted for consent. During interview, the Infection Preventionist stated she was responsible for overseeing the resident’s vaccination status and confirmed there was no evidence in the record that the vaccine had been offered, declined, or contraindicated, and that the HCP should have been contacted so the vaccine could be administered.
Failure to Offer COVID-19 Vaccination to a High-Risk Resident
Penalty
Summary
The facility failed to offer COVID-19 immunization to one resident, identified in the report as Resident #119, out of five applicable residents reviewed for COVID-19 vaccination. Resident #119 had diagnoses including COPD and dependence on supplemental oxygen, had an invoked Health Care Proxy, and the medical record showed the resident’s COVID-19 vaccination was not up to date on the 1/2/26 MDS assessment. The record also showed the resident’s last COVID-19 immunization was on 3/2/23. Review of the medical record did not include evidence that the 2025-2026 Spikevax COVID-19 vaccine had been offered, declined, or identified as contraindicated. During interview, the Infection Preventionist stated she was responsible for overseeing vaccination status for Resident #119 and confirmed there was no evidence in the record that the vaccine had been offered, declined, or contraindicated. She also stated the resident’s HCP should have been contacted for consent for COVID-19 immunization and noted the resident was at high risk for COVID-19 complications due to COPD.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Trinity Eastern Orthodox N & R Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Regalcare At Worcester | 1.5 mi | ★★★★★ | 0 | 0 |
| Knollwood Nursing Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Christopher House Of Worcester | 1.9 mi | ★★★★★ | 9 | 0 |
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