Oxford Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 689 Main Street, Haverhill, Massachusetts 01830
- CMS Provider Number
- 225218
- Inspections on file
- 19
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oxford Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide a homelike environment, with surveyors observing unclean and damaged conditions on both floors. Issues included stained ceilings, scuffed walls, broken furniture, and mouse droppings. The Director of Housekeeping and Maintenance Director acknowledged the problems, citing the building's age and resident habits as contributing factors.
The facility failed to maintain its infrastructure, with surveyors observing stained and bulging ceiling tiles due to a leaking roof that had not been repaired for at least three years. Additionally, residents reported significant rodent activity, indicating an ineffective pest control program. The Maintenance Director confirmed the ongoing issues with the roof and delays in replacing damaged tiles, while residents described frequent encounters with mice in their rooms.
The facility's pest control program was ineffective, as evidenced by mouse droppings and structural issues observed in resident rooms on two floors. Despite a service agreement for monthly inspections, resident bedrooms were not treated in November, December, and March. Residents reported frequent mouse sightings and inadequate pest control measures in their living areas.
The facility failed to implement care plans for several residents, resulting in deficiencies in meal supervision and heel offloading. Residents with cognitive impairments and specific supervision needs were left unsupervised during meals, contrary to their care plans. Additionally, a resident with brain cancer and dementia did not have their heels offloaded as required by doctor's orders. Staff interviews confirmed a lack of awareness and adherence to these care plans.
A resident with PTSD, anxiety, and depression reported missing personal items, but the grievance was not addressed according to the facility's policy. Despite informing staff and submitting a written grievance, the issue was not logged or investigated. Staff interviews revealed a lack of communication and availability of grievance forms, and the grievance officer was not informed. The administrator was unaware of the grievance, and it was not recorded in the grievance binders.
A resident with PTSD, anxiety, and depression reported a sexual assault to staff, but the LTC facility failed to report the allegation to state officials and police within the required timeframe. Despite the facility's policy, the Director of Nursing acknowledged the report was initiated but not submitted, leading to a deficiency in reporting the alleged abuse.
A resident with traumatic brain dysfunction and dysphagia experienced significant weight gain due to the facility's failure to follow physician-prescribed parameters for enteral nutrition. Despite the resident consuming 75-100% of meals, nursing staff administered additional enteral nutrition, leading to a 13.6-pound weight gain over three months. The Director of Nursing acknowledged the staff's failure to adhere to the prescribed parameters.
A facility failed to implement proper PICC line care and medication orders for a resident with serious infections. The resident's antibiotic administration and saline flushes were inconsistently documented, and required PICC line site assessments, dressing changes, and other procedures were not performed as per policy. Observations showed the dressing was undated and dirty, and staff interviews confirmed the lack of adherence to facility policy.
A resident lost their bottom dentures and could not afford replacements. Despite attending a dental appointment and being informed of the costs, the facility did not schedule further appointments or implement immediate interventions to address the resident's chewing difficulties. The facility's policy requires prompt referral and documentation, but no action was taken until 50 days later, when the RD updated the resident's food preferences.
The facility failed to document and manage the care of two residents with PICC lines, missing records for medication administration, site assessments, and dressing changes. Observations showed inadequate PICC line care, confirmed by staff interviews.
The facility's QAPI program was ineffective in addressing environmental concerns, including a persistent mice problem and maintenance issues. Residents reported mice droppings in their rooms, and the administrator acknowledged ongoing issues with cleanliness and repairs. Despite hiring a pest control company, the facility struggled to manage the mice problem effectively.
A nurse was observed using her fingers to dispense medications into a cup, contrary to the facility's policy on medication administration, which prohibits touching medications. The nurse admitted to the error during an interview.
A resident reported a malfunctioning call system in their room, which had been broken for weeks despite notifying nursing staff. The call lights for all beds were activated without being pulled, and the Maintenance Director was unaware of the issue.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents on both the first and second floors, as evidenced by numerous observations of unclean and damaged conditions. On the second floor, surveyors noted brown stains on bathroom ceilings, scuffed and unpainted walls, broken furniture, and mouse droppings in multiple rooms. Additionally, there were issues with broken floor tiles, non-functioning bathroom lights, and rusted heat vents. The presence of mouse droppings was confirmed by both a Certified Nurse's Aide and the Director of Housekeeping Services, who acknowledged that the rooms were not clean despite having been cleaned earlier that day. On the first floor, similar deficiencies were observed, including gaps under door sweeps, gouged ceiling tiles, and mold-like dark splotches in shower rooms. Several rooms had scuff marks, broken tiles, leaking sinks, and mismatched paint. Mouse droppings were also found on the floors, and residents reported issues such as leaking ceilings and non-functional air conditioning units. The Maintenance Director confirmed ongoing problems with roof leaks and mice, attributing some of the issues to the building's age and residents leaving food out. Throughout the facility, there were consistent reports of unpainted plaster, peeling wallpaper, and dirty, grimy floors. The Maintenance Director admitted to struggling with keeping up with repairs due to the building's condition and the persistent presence of mice. These observations and interviews highlight a significant failure to provide a safe, clean, and comfortable environment for residents, as required by regulatory standards.
Facility Infrastructure and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain its infrastructure effectively, resulting in chronic and widespread damage due to a leaking roof. Surveyors observed numerous stained and bulging ceiling tiles in resident bedrooms and common areas on both the first and second floors. The Maintenance Director confirmed that the roof had been leaking for at least three years, and although quotes for roof replacement had been obtained, management had not approved any repairs. The Maintenance Director also noted difficulties in keeping up with replacing damaged ceiling tiles due to the persistent leaks and delays in ordering new tiles. Additionally, the facility lacked an effective pest control program, as evidenced by multiple resident reports of rodent activity. Residents on the first floor reported hearing rodents running on top of ceiling tiles and seeing mice in their rooms, with some residents experiencing mice on their beds or shoulders. These observations and resident interviews indicate a significant pest issue that has not been adequately addressed by the facility.
Ineffective Pest Control Program in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program on two resident-occupied floors, as evidenced by multiple observations and interviews. The Pest Control Services Agreement, dated August 8, 2018, stipulated monthly inspections and treatments for pests, including rodents, with resident bedrooms treated upon request. However, from September 2023 through February 2024, while the building was inspected and treated, the logs indicated that resident bedrooms were not inspected or treated in November and December 2023, nor in March 2024. The logs also recorded 24 reports of mice sightings in various locations, including bedrooms, bathrooms, and common areas. On March 28 and 29, 2024, surveyors observed mouse droppings in numerous rooms on both the first and second floors, with additional structural issues such as holes in ceilings and gaps under doors that could facilitate rodent entry. Interviews with residents revealed frequent mouse sightings, including mice entering and exiting holes in ceilings and under bathroom cabinets, and even a dead mouse found in a resident's purse. Residents reported that the pest control technician treated hallways and common areas but not the bedrooms, contributing to the ongoing pest issue.
Failure to Implement Care Plans for Supervision and Heel Offloading
Penalty
Summary
The facility failed to implement care plans for five residents, leading to deficiencies in supervision during meals and heel offloading. For four residents, the facility did not provide the required supervision during meals as outlined in their care plans. One resident, with a history of suicide attempts, was observed with a plastic fork on their meal tray, contrary to the care plan that specified rounded utensils for safety. Another resident, who was severely cognitively impaired, was observed eating without supervision, despite the care plan requiring continual supervision. Additionally, a resident with severe cognitive impairment and a history of Alzheimer's disease was left unsupervised during meals, contrary to the care plan that required supervision and assistance. Another resident, who required substantial assistance due to progressive dementia, was observed with an untouched meal tray and no staff present to assist or encourage eating. The lack of supervision was confirmed by interviews with staff, who were unaware of the specific supervision requirements for these residents. Furthermore, the facility failed to offload the heels of a resident with brain cancer and dementia, as per the doctor's orders. The resident was observed multiple times with heels not offloaded, both in bed and in a reclining chair. Staff interviews revealed that the resident was supposed to have a pillow under their calves to prevent pressure on the heels, but this was not implemented. These observations indicate a failure to adhere to the care plans and doctor's orders, resulting in deficiencies in resident care.
Failure to Address Resident Grievance on Missing Personal Items
Penalty
Summary
The facility failed to address a grievance regarding missing personal items for a resident diagnosed with PTSD, anxiety, and depression. The resident, who was cognitively intact, reported that a box containing makeup, facial products, and jewelry had been missing for over a week. Despite informing multiple staff members and submitting a written grievance to the facility receptionist, the grievance was not logged, reviewed, or investigated as per the facility's grievance policy. Interviews with staff, including a CNA, unit secretary, and the facility receptionist, revealed that the grievance process was not properly followed, and the grievance was not communicated to the social worker or logged in the grievance binders. The facility's grievance policy requires the appointment of a grievance officer to oversee the process, including receiving, tracking, and investigating grievances, and maintaining confidentiality. However, the grievance officer, who is the Director of Social Services, was not informed of the resident's grievance. Additionally, grievance forms were not readily available on the unit, and staff failed to facilitate the grievance process as expected. The administrator was unaware of the missing items and confirmed that grievances should be filed in the grievance binders, which did not contain any record of the resident's grievance.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to state officials within the required timeframe. The resident, who was cognitively intact and had a history of PTSD, anxiety, and depression, reported being sexually assaulted during the night. The resident informed the nurse and the unit secretary about the incident. The unit secretary then reported the incident to Unit Manager #1, who subsequently informed the Director of Nursing (DON). Despite the facility's policy requiring immediate reporting of such allegations to state officials within two hours, the report was not submitted. The DON acknowledged that the report was initiated but never submitted to the State Agency. Additionally, the incident was not reported to the police, as required by the facility's policy. The incident report form confirmed that the allegation had not been submitted to the State Agency or reported to the police. The resident expressed a desire for the incident to have been reported to the police. This series of inactions led to the deficiency in reporting the alleged abuse as per the facility's policy and state requirements.
Failure to Adhere to Enteral Nutrition Parameters
Penalty
Summary
The facility failed to administer enteral nutrition to a resident according to physician-prescribed parameters, resulting in a clinically significant and unintentional weight gain. The resident, who was admitted with traumatic brain dysfunction and required partial assistance with eating, was receiving enteral nutrition via a gastrostomy tube due to dysphagia. The physician's order specified that the resident should only receive the enteral nutrition formula if they consumed less than 75% of their meals. However, the facility's nursing staff administered the enteral nutrition formula even when the resident consumed 75-100% of their meals, leading to a weight gain of 13.6 pounds over three months. Interviews with staff and review of documentation revealed that the nursing staff did not adhere to the prescribed parameters, administering 240 mL of enteral nutrition formula multiple times despite the resident's adequate oral intake. The resident's family member expressed concern over the weight gain, noting that the resident was already overweight and had a recent cardiac event. The Director of Nursing acknowledged that the staff should have followed the prescribed parameters for enteral nutrition orders, indicating a failure in adhering to professional standards of care.
Failure to Implement PICC Line Care and Medication Orders
Penalty
Summary
The facility failed to properly implement medication orders and treatments for a resident with a peripherally inserted central catheter (PICC) line. The resident, who was admitted in March 2024, had active diagnoses including acute and subacute infective endocarditis, acute osteomyelitis of vertebrae, and discitis. The facility did not document the administration of the antibiotic ceftriaxone and saline flushes consistently, with records showing administration only on select days, leaving 13 out of 19 days undocumented. Additionally, the facility did not adhere to its policy for PICC line site assessments, dressing changes, and other related procedures. The Infusion Therapy Flowsheet and nursing notes indicated that site assessments were documented only on two occasions, with no documentation of weekly dressing changes, needleless connector changes, daily tubing changes, or weekly measurements of the catheter length. Observations by the surveyor revealed that the PICC line dressing was undated, dirty, and partially lifted, and the resident reported that the tubing or dressing had not been changed since admission. Interviews with facility staff, including the Clinical Nurse, Nursing Supervisor, and Director of Nursing, confirmed the lack of documentation and adherence to facility policy. The staff acknowledged that there were no documented external catheter length measurements, needleless connector changes, tubing changes, or dressing changes until late March 2024, despite the facility's policy requiring these actions to be performed and documented regularly.
Failure to Replace Lost Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who lost their bottom dentures. The resident, who was cognitively intact and had a diagnosis of malnutrition, reported losing their dentures in November 2023. Despite attending a dental appointment in December 2023, where they were informed of the cost for replacement dentures, the resident could not afford them, and no further plans or appointments for denture replacement were made by the facility. The facility's policy requires prompt referral to dental services within three days of denture loss, along with documentation of measures taken to ensure the resident can eat and drink adequately. However, the facility did not implement any interventions to address the resident's difficulty in chewing until 50 days after the dentures were reported missing. The Registered Dietitian updated the resident's food preferences in January 2024, but there was no immediate action taken by the nursing staff when the dentures were initially lost. Interviews with the Unit Manager and the Administrator revealed that the staff were aware of the dentist's recommendations and the financial implications for the resident. However, the Administrator was not informed of the missing dentures, and the facility did not take responsibility for the cost of replacement dentures, despite the resident's inability to afford them. This lack of action resulted in the resident experiencing ongoing difficulty with chewing.
Deficiencies in PICC Line Management and Documentation
Penalty
Summary
The facility failed to properly document and manage the care of two residents with peripherally inserted central catheter (PICC) lines. For Resident #63, the facility did not document the administration of the antibiotic ceftriaxone and saline flushes consistently, with records missing for 13 out of 19 days. Additionally, there was a lack of documentation for PICC line site assessments, dressing changes, needleless connector changes, tubing changes, and measurements of the external catheter length. Observations revealed that the PICC line dressing was undated, dirty, and partially detached, and the resident reported that the dressing and tubing had not been changed since admission. Similarly, for Resident #115, the facility failed to document the administration of vancomycin and cefepime antibiotics, as well as saline flushes, for 12 consecutive days. There was also a lack of documentation for site assessments, dressing changes, needleless connector changes, and external catheter length measurements. The facility's records did not reflect the required care and monitoring of the PICC line as per the facility's policy and physician orders. Interviews with the Clinical Nurse, Nursing Supervisor, and Director of Nursing confirmed the lack of documentation and adherence to facility policies regarding PICC line management. The staff did not follow the established protocols for medication administration and PICC line care, leading to significant gaps in the residents' medical records and potential risks to their health and safety.
Ineffective QAPI Program and Environmental Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by their inability to systematically analyze and address quality deficiencies. Despite having a policy in place that outlines the design and scope of the QAPI program, the facility did not effectively measure the success of implemented actions or track performance to ensure sustained improvements. This deficiency was highlighted by ongoing environmental concerns, including pest control issues, cleanliness, and necessary repairs, which were not adequately monitored or resolved. Interviews and observations revealed that residents reported an increase in mice presence, with droppings found in their rooms and mice entering through holes in the walls. The facility's administrator acknowledged the ongoing mice problem and other environmental issues such as stained ceiling tiles, dirty rooms, broken equipment, and furniture. Although a pest control management company was hired, the facility struggled to manage the mice problem effectively, indicating a lack of systematic follow-up and evaluation of corrective actions.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to ensure staff adhered to infection control practices during a medication pass. The facility's policy titled 'Medication Administration-Oral' dated June 2015, specifically indicated that staff should not touch the medication when opening the bottle or unit dose packaging. However, during a medication pass, a surveyor observed a nurse dispensing five medications by using her fingers to place the medications into a medication cup. During an interview shortly after the observation, the nurse acknowledged that she should not have touched the medication.
Malfunctioning Call System in Resident's Room
Penalty
Summary
The facility failed to ensure a properly functioning call system in a resident's room on the first floor. During an observation, the surveyor noted that the call light system in room [ROOM NUMBER] was malfunctioning, as all three beds' call lights were activated without being pulled. A resident in Bed C explained that the call light apparatus was broken and required the string to be positioned in a specific way to deactivate the system. The resident reported that the issue had persisted for many weeks and had been communicated to the nursing staff multiple times, yet it remained unresolved. The Maintenance Director, when interviewed, stated he was unaware of the malfunction and had not been informed by the nursing staff.
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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