Palmer Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Palmer, Massachusetts.
- Location
- 250 Shearer Street, Palmer, Massachusetts 01069
- CMS Provider Number
- 225763
- Inspections on file
- 25
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Palmer Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to undignified treatment when an activity aide jiggled the resident's neck skin and laughed in front of others. This behavior was witnessed by staff, who intervened and reported the incident. The aide later admitted to the action, which was found to violate facility policies on dignity and respect.
A staff member failed to immediately report a witnessed incident where another staff member engaged in inappropriate physical and verbal behavior toward a resident with severe cognitive impairment. The incident, which included mocking and derogatory language, was not reported until the following day, contrary to facility policy requiring immediate reporting of abuse allegations.
A CNA failed to immediately report a witnessed incident of verbal abuse by another CNA toward a resident with severe cognitive impairment and total care needs. The incident occurred during a meal, where the resident was subjected to a loud, derogatory comment in front of others. The witnessing CNA delayed reporting the event to the Executive Director, contrary to facility policy requiring immediate reporting of abuse allegations.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as dust-laden equipment, improper use of hair restraints, and inadequate testing of dish machine sanitation levels. Staff were observed not following proper procedures, leading to potential contamination risks.
A resident with severe cognitive impairment and under guardianship was subjected to unauthorized video monitoring in their bedroom, with images displayed at the nursing station. The facility failed to obtain consent, a physician's order, or develop a care plan for the monitoring, violating the resident's dignity and privacy. The DON acknowledged the lack of policy and consent, highlighting a significant oversight in respecting the resident's rights.
A resident at risk for falls, with conditions including Parkinson's Disease and Diabetes Mellitus, was observed without access to a call bell, contrary to the facility's policy and the resident's care plan. The resident, who was cognitively intact and required assistance, was twice found in a wheelchair without the call bell within reach, highlighting a failure to accommodate the resident's needs.
The facility failed to maintain correct air mattress settings for two residents at risk of skin breakdown. One resident's mattress was set to 85 pounds instead of the prescribed 135 pounds, while another's was set to 210 pounds instead of between 120 and 150 pounds. Despite documentation indicating regular checks, staff were unaware of the incorrect settings, leading to discomfort and potential risk for the residents.
A resident with severe cognitive impairment and identified as an elopement risk was observed unsupervised on a patio with an open gate leading to a parking lot and main road. The facility's policy required supervision for such residents, but the practice of scheduled supervised outdoor time had been discontinued. The DON acknowledged the resident's elopement risk and the concern of the open gate, highlighting a deficiency in maintaining a safe environment.
A resident on a mechanically soft diet due to dysphagia was provided with meals that did not meet their dietary needs, including regular consistency and pureed items not ordered or preferred. The resident expressed dissatisfaction with the food, and staff interviews revealed a lack of awareness and education regarding the resident's dietary restrictions. The Food Service Director and Staff Development Coordinator acknowledged discrepancies in meal preparation and staff training.
A resident with severe cognitive impairment was at risk of injury due to a scoop mattress that was incompatible with the bed frame, creating a significant gap at the foot of the bed. The mattress change was made without notifying maintenance staff, and no safety audit was conducted at the time, contrary to the facility's bed safety policy.
Resident Not Treated with Dignity by Activity Aide
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence on staff for care was not treated with dignity and respect by an activity aide. The aide, in the presence of other residents and staff, used his fingers to jiggle the loose skin under the resident's neck while laughing and repeatedly calling the resident's name. This action was witnessed by another activity aide, who immediately told the aide to stop and described the behavior as rude. Additional staff members were aware of the incident, with one hearing the aide make a comment and begin playing with the resident's neck, and another hearing the admonishment that the behavior was not funny. The resident involved had a diagnosis of unspecified dementia with associated anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The incident took place in the facility's dining/activity room, where several residents and staff were present. The aide involved later stated that he intended to be playful and did not perceive his actions as inappropriate, but acknowledged tickling the resident's neck skin. The incident was reported to the activity director and subsequently to the DON, who initiated an internal investigation. Facility policies reviewed by surveyors clearly stated that residents are to be treated with dignity and respect at all times, and that demeaning practices are prohibited. The actions of the activity aide were found to be in violation of these policies, as the resident was subjected to undignified treatment in a public setting, witnessed by both staff and other residents.
Failure to Immediately Report Witnessed Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to immediately report a witnessed incident of potential verbal and physical abuse involving a resident with severe cognitive impairment and total dependence on staff for care. The facility's Abuse Prevention Program policy required all employees to immediately report any violations or alleged violations, but this protocol was not followed. An activity aide observed another aide flicking the loose skin under a resident's chin while mimicking a sound and laughing, as well as calling the resident derogatory names after an incident with a tablet. The aide who witnessed the incident did not report it to the Activity Director until the following day and did not provide full details until later that afternoon. Interviews confirmed that the aide recognized the interaction as inappropriate but did not think to report it immediately, despite facility policy. The delay in reporting was acknowledged by both the Activity Director and the Director of Nursing, who stated that the incident should have been reported right away. The resident involved had a diagnosis of unspecified dementia with anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The failure to promptly report the observed abuse placed this resident and potentially others at risk, as required procedures for immediate reporting were not followed.
Failure to Immediately Report Witnessed Verbal Abuse
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) witnessed an incident of verbal abuse directed at a resident with severe cognitive impairment and failed to report the incident immediately, as required by the facility's Abuse Prevention Program policy. The incident took place during lunch, when one CNA overheard another CNA, who was an agency staff member, make a loud, derogatory comment about the resident in the presence of the resident and three others at the dining table. The resident involved had diagnoses including Down Syndrome, unspecified dementia, and seizures, and was dependent on staff for care. Due to the resident's severe cognitive impairment, he or she was unable to respond to questions about the incident. The CNA who witnessed the event did not report the alleged abuse to the Executive Director until one hour and forty-five minutes after the incident, instead proceeding to provide care to another resident. The delay in reporting was acknowledged by the CNA during an interview, stating that the incident should have been reported immediately. Other staff, including a nurse present at the time, were not informed of the incident by the witnessing CNA. The facility's policy requires all employees to immediately report any violations or alleged violations, and this requirement was not followed in this case.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, which is essential to prevent contamination and the spread of foodborne illnesses. During an initial kitchen tour, the surveyor observed dust-laden fans, a dusty shelf under a portable air conditioner, and a dusty utensil rack over the cook's preparation area. Additionally, clear stacked storage containers were found to be wet inside, indicating they were not thoroughly dried, which could lead to mold and bacterial growth. Dietary Aide #4 confirmed that the containers should not have been stacked while wet. The facility also failed to ensure that hair restraints were worn by staff to prevent potential physical contamination of food and fluids. During a follow-up visit, a staff member was observed preparing food without a hair restraint, acknowledging that a hair net should have been worn. The utensil rack remained dusty, indicating ongoing issues with cleanliness and sanitation in the kitchen area. Furthermore, the facility did not appropriately test the dish machine for temperature and sanitation requirements. Dietary Aide #2 was observed running the dish machine without checking the chemical sanitizer levels, which were found to be too high. The aide admitted to not being educated on when to check the sanitizer. Upon further inspection, it was discovered that the test strips used to check the sanitizer were expired, and the dish machine was not meeting the required sanitation standards. The Food Service Director acknowledged these issues and the need for proper checks before using the dish machine.
Unauthorized Video Monitoring of Resident
Penalty
Summary
The facility failed to ensure respect and dignity for a resident by implementing video monitoring in the resident's bedroom without obtaining consent. The resident, who was admitted with a diagnosis of dementia and had severe cognitive impairment, was under guardianship due to incapacity to make personal decisions. The video camera was positioned in the resident's room, capturing images that were displayed on a monitor at the nursing station, exposing the resident's body without consent. The facility's policy on dignity emphasized the importance of respecting residents' private space and property, which was not adhered to in this case. The deficiency was further highlighted by the lack of documentation in the resident's medical record regarding the need for video monitoring, a physician's order, or a comprehensive, person-centered care plan. Interviews with facility staff, including the Director of Nursing, revealed that the video monitoring had been in place for several months without proper assessment, consent from the resident's guardian, or a policy governing its use. The Director of Nursing acknowledged the oversight and confirmed that the facility did not have a policy on video monitoring, and consent was not obtained, which was a concern for the resident's dignity.
Failure to Provide Call Bell Access for Fall-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident identified as being at risk for falls by not ensuring the resident had access to their call bell at all times. The facility's policy on call bells, dated May 28, 2021, mandates that call bells should be placed within reach of residents to allow them to call for assistance. However, during observations on September 26, 2024, the surveyor noted that the resident's call bell was hanging behind the bed and was not within reach, despite the resident being in a wheelchair and needing assistance to move. The resident, who was admitted with diagnoses including Parkinson's Disease, Diabetes Mellitus, and urinary frequency, was assessed as cognitively intact and at risk for falls. The resident's care plan specifically included keeping the call bell within reach as a fall prevention measure. Despite this, the resident was observed twice without access to the call bell, once while sitting in a wheelchair next to the bed and again while eating breakfast. The Director of Nursing confirmed that call bells should always be within reach of residents, indicating a failure to adhere to the facility's policy and the resident's care plan.
Failure to Maintain Correct Air Mattress Settings for Residents at Risk of Skin Breakdown
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents at risk of skin breakdown. For one resident, the facility did not maintain the pressure-reducing air mattress settings as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed with the air mattress set to 85 pounds instead of the prescribed 135 pounds. Despite documentation indicating that the mattress settings were checked every shift, the incorrect setting was observed on multiple occasions, and staff were unaware of the resident's history of pressure ulcers. For another resident, the facility failed to implement the physician's order for an air mattress set between 120 and 150 pounds. The resident, who was bed-bound and at increased risk for skin breakdown, was observed with the air mattress set to 210 pounds, contrary to the physician's order. Despite documentation indicating that the mattress settings were checked every shift, the incorrect setting was observed on multiple occasions. The resident reported discomfort, and staff were unaware that the mattress was not set correctly. The facility's policy on support surfaces emphasizes the importance of pressure redistribution and individual resident needs. However, the observations and interviews revealed that the facility did not adhere to these guidelines, resulting in the failure to provide appropriate care for residents at risk of skin breakdown. The Director of Nursing acknowledged the discrepancies in mattress settings and the need for staff to check and correct settings every shift.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident identified as at risk for elopement. The resident, who had a history of bipolar disorder with psychotic features, dementia with behavioral disturbance, and severe cognitive impairment, was observed outside the facility on a patio without staff supervision. The patio had an open gate leading to a sidewalk, ramp, parking lot, and main road, posing a potential risk for elopement. The facility's policy on wandering and elopement required that residents identified as at risk should have care plans with strategies and interventions to ensure their safety. Despite this, the resident's care plan allowed for unsupervised patio time, which conflicted with the resident's identified elopement risk. The resident required substantial assistance with ambulation and had a history of being verbally abusive and having psychiatric diagnoses, further emphasizing the need for supervision. Interviews with facility staff, including a CNA and the DON, revealed that the facility had previously provided scheduled supervised outdoor time for residents, but this practice had been discontinued. The DON acknowledged that the resident was an elopement risk and should have been supervised, and that the open gate on the patio was a concern. The lack of supervision and the open gate contributed to the deficiency in ensuring a safe environment for the resident.
Failure to Provide Prescribed Diet Consistency
Penalty
Summary
The facility failed to provide food that met the individual dietary needs of a resident, who was on a physician-prescribed mechanically soft diet due to dysphagia and other health conditions. Despite the prescribed diet, the resident was offered regular consistency items and pureed meals that were not ordered or preferred. The resident expressed dissatisfaction with the food, describing it as "crappy" and "like glue," and was observed to receive meals that did not align with the prescribed diet, such as pureed pancakes and ground sausage instead of appropriately moistened and chopped items. The facility's policy required that therapeutic diets be based on individual needs and prescribed by a physician, yet the resident's meals did not adhere to these guidelines. Observations revealed that the resident was provided with meals that included pureed items and inappropriate foods like a peanut butter and jelly sandwich, which was not allowed on the resident's diet. Staff interviews indicated a lack of awareness and education regarding the specific dietary needs and restrictions of the resident, contributing to the failure to provide the correct diet. The Food Service Director acknowledged the discrepancies in meal preparation and expressed uncertainty about whether nursing staff received education on the facility's diet consistencies. The Staff Development Coordinator also confirmed a lack of diet education for nursing staff. These oversights in staff training and meal preparation led to the resident receiving meals that did not meet their dietary needs, resulting in dissatisfaction and uneaten food.
Incompatible Mattress Poses Risk of Entrapment
Penalty
Summary
The facility failed to ensure the safety of a resident by using a scoop mattress that was incompatible with the bed frame, resulting in a significant gap between the mattress and the footboard. This gap posed a risk of injury or entrapment for the resident, who had severe cognitive impairment due to dementia and was under guardianship. The resident was observed multiple times lying on the scoop mattress with a nine-inch gap at the foot of the bed, which was confirmed by the surveyor's measurements. The deficiency occurred because the facility did not follow its policy of ensuring bed safety through proper assessment and maintenance. The mattress change was made by a weekend staff nurse without notifying the maintenance staff, who were responsible for ensuring compatibility and safety. The Director of Nursing admitted that no safety audit was conducted at the time of the mattress change, and the facility lacked a specific policy for auditing bedframe or mattress safety, relying instead on quarterly audits by the maintenance department.
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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