Park Avenue Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Massachusetts.
- Location
- 146 Park Avenue, Arlington, Massachusetts 02174
- CMS Provider Number
- 225584
- Inspections on file
- 27
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Park Avenue Health Center during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering exited a secured unit and the facility undetected by staff, following a visitor onto an elevator and out the front entrance. The resident was later found outside with a fractured elbow. Facility staff failed to provide adequate supervision and did not follow protocols for monitoring residents and visitors, resulting in the resident's elopement and injury.
A facility failed to document wound measurements for a resident following their readmission after a hospital stay. The resident, with chronic osteomyelitis and stage four pressure injuries, had no documented measurements for six days post-readmission, despite facility policies requiring such documentation. The DON acknowledged the importance of these measurements for tracking wound progression.
A resident with severe cognitive impairment eloped from an LTC facility due to inadequate supervision and security measures. The resident, known for exit-seeking behavior, was found injured and dehydrated in a neighboring town. The facility also failed to secure a patio area, allowing residents unsupervised access, contrary to policy. Staff were unaware of residents having keypad codes, and gates were left open, contributing to the incident.
The facility failed to adhere to food service safety standards by allowing a cook to contaminate ready-to-eat food with gloves that had been used to touch various surfaces. Despite the facility's policy requiring gloves to be changed between tasks, the cook used the same contaminated gloves to handle edible flowers and hot dog buns for resident plates. This was confirmed by the Food Service Director, who emphasized the importance of preventing contamination.
A facility failed to obtain a signed psychotropic informed consent for a resident with severe cognitive impairment and a court-appointed guardian. The resident was receiving Lithium Carbonate for bipolar disorder without a signed consent form. The DON reported difficulties in contacting the healthcare proxy and guardian, and the medication was administered without consent to avoid potential harm.
A resident's room in an LTC facility was found to have a persistent strong odor due to inadequate maintenance of a purewick system used for incontinence care. Despite daily cleaning, the room had not been deep cleaned recently, and staff were aware of the odor issue but had not increased cleaning frequency. The resident, who is cognitively intact and dependent on assistance, expressed dissatisfaction with the room's condition, particularly while eating meals.
The facility failed to resolve a grievance filed by a resident about staff sleeping during their shift. The facility's Grievance Policy requires a written report of findings within 72 hours and informing the complainant of actions taken within 3-5 working days. However, no resolution was documented for the grievance, and the Director of Nursing acknowledged this oversight.
A facility failed to assess mattress bolsters as a potential restraint for a resident with severe cognitive impairment. The resident had bolsters under the fitted sheet to prevent climbing out of bed, but no restraint assessment, physician's order, or care plan documentation was completed. Staff interviews confirmed the absence of a formal assessment, leading to a deficiency in ensuring the resident's freedom from unnecessary restraints.
The facility failed to report allegations of potential abuse for three residents, including derogatory comments and rough handling by staff. Despite the Social Worker and DON acknowledging the need for investigation and reporting, these incidents were not reported to the state agency, violating the facility's abuse and neglect policy.
The facility failed to investigate allegations of potential abuse for three residents. A resident with intact cognition reported a nurse's derogatory comment, another with moderate cognitive impairment reported a hurtful comment from a CNA, and a severely impaired resident's representative reported rough handling and neglect. The facility did not conduct required investigations for these grievances.
A facility inaccurately documented a resident's use of an indwelling catheter in the MDS assessment. The resident, with cerebral infarction and diabetes, was cognitively intact. The MDS incorrectly indicated an indwelling catheter, while records showed the use of a purewick catheter, an external device. Staff interviews confirmed the coding error.
A resident with severe cognitive impairment and a right upper extremity contracture was not provided with a prescribed orthotic for contracture management. Despite physician orders for a resting hand splint to be worn nightly, observations showed the resident was not wearing the orthotic, and it was not found in the room. The Unit Manager confirmed the order, but nursing notes did not document any refusal by the resident. The DON expects all orders to be followed, highlighting a deficiency in care plan adherence.
A resident with an unstageable pressure wound on the right heel did not receive proper wound care as per the Wound Physician's recommendations. The resident was observed with their foot directly on the bed without the prescribed heel protective booties, and the air mattress was not set to the resident's weight. Interviews with staff confirmed the need for these interventions, but they were not consistently implemented.
A resident with chronic respiratory failure was observed receiving oxygen at a flow rate higher than the physician's order of 1-2 LPM. The oxygen concentrator was set at four LPM on multiple occasions, contrary to the prescribed range. A nurse later corrected the setting to two LPM. The DON acknowledged the importance of adhering to physician's orders to prevent adverse effects.
A facility failed to create a comprehensive trauma-informed care plan for a resident with PTSD. The resident's care plan included general interventions but lacked specific triggers and individualized strategies for PTSD. The social worker was unaware of the PTSD diagnosis, and the psychiatric evaluation and psychotherapy notes did not document it, highlighting a gap in care planning.
A resident with heart failure received double the prescribed dose of Torsemide due to a failure in the monthly medication review (MRR) process. The resident had two active orders for Torsemide, each for 40 mg, leading to a total of 80 mg being administered daily. The MRR did not identify this irregularity, and interviews with facility staff confirmed the expectation for such discrepancies to be recognized.
A resident with heart failure received a double dose of Torsemide for 27 days due to two separate physician orders, leading to significant weight loss and elevated BUN/creatinine levels. The error was not identified by the facility's medication administration processes or during the monthly medication review. The issue was only acknowledged after a review by a nurse and surveyor, prompting clarification from the nurse practitioner.
Elopement and Injury Due to Inadequate Supervision and Lapse in Security Protocols
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with diagnoses including Alzheimer's Disease, cognitive communication deficit, amnesia, and dementia with moderate agitation, was able to exit a secured unit and leave the facility undetected by staff. The resident was later found sitting on the curb in front of the facility and was subsequently transferred to the hospital emergency department, where a left elbow fracture was diagnosed. The resident's care plan indicated the need for increased supervision and distraction with alternative activities to maintain safety. Facility policies required identification of residents at risk for unsafe wandering and the implementation of supervision based on individual needs and environmental hazards. The policies also specified that staff must monitor visitors and ensure that residents do not leave the secured unit or facility without appropriate supervision. On the day of the incident, a visitor was touring the secured unit and was allowed access to the elevator by a staff member. The resident followed the visitor onto the elevator and exited the building, apparently unnoticed by staff at the reception desk, who was responsible for monitoring entry and exit. Interviews revealed that staff members on the unit denied entering the elevator code for the visitor, and the receptionist did not realize the resident had exited. The Director of Nursing confirmed that staff were expected to remain at the elevator until it closed to ensure no residents left the secured unit. The failure to provide adequate supervision and to follow established protocols for monitoring residents and visitors resulted in the resident's elopement and subsequent injury.
Failure to Document Wound Measurements Post-Readmission
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following their readmission after a hospital stay. Specifically, there was no nursing documentation related to wound measurements for six days after the resident's readmission. The facility's policy requires that all services provided to the resident, progress towards care plan goals, or any changes in the resident's condition be documented in the medical record. Additionally, the facility's protocol mandates that nursing staff conduct an admissions assessment, including a skin assessment, and document a full assessment of pressure injuries, including measurements. The resident, who was admitted to the facility in December 2024, had diagnoses including chronic osteomyelitis, polyneuropathy, and a stage four pressure injury at the sacral region. Upon readmission to the facility, the admission assessment noted pressure injuries on the coccyx, left buttock, and right buttock, but the section for documenting measurements was left blank. The Director of Nurses confirmed that wound measurements are crucial for tracking progression and should have been documented upon the resident's readmission.
Inadequate Supervision and Security Lead to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a history of exit-seeking behavior and was assessed as being at increased risk for elopement, was last seen before lunch and was found the next day at a convenience store in a neighboring town. The resident sustained injuries, including cuts, bruises, and dehydration, and was admitted to the hospital. Staff interviews revealed that the resident had been exhibiting exit-seeking behavior throughout the day, and the alarm on the exit door had been broken, allowing the resident to leave the facility undetected. Additionally, the facility failed to secure the fenced-in patio area used by residents for smoking and outside activities. During the survey, multiple residents were observed entering the keypad code to access the patio area without staff supervision. The gate leading to the facility parking lot was found wide open, providing an easy escape route for residents at risk of elopement. The facility's policy required staff supervision for residents in the smoking area, but observations showed that residents were left unsupervised, contrary to the policy. The facility's policies on safety and supervision were not effectively implemented, as evidenced by the lack of staff presence in critical areas and the failure to secure exit points. The Director of Nursing and other staff members were unaware that residents had access to keypad codes, and the gates in the smoking area were not kept locked as required. These lapses in supervision and security contributed to the resident's elopement and subsequent injuries.
Food Handling Deficiency Due to Contaminated Gloves
Penalty
Summary
The facility failed to handle food in accordance with professional standards for food service safety, specifically by allowing contamination of ready-to-eat food during service. The facility's policy on Food Preparation and Services, revised in April 2022, mandates that food preparation staff adhere to proper hygiene and sanitary practices, including prohibiting bare hand contact with food and requiring gloves to be worn and changed between tasks. However, during a lunch tray line observation, a cook was seen contaminating his gloves by touching lids of pans and plastic wrap, and then using the same contaminated gloves to handle edible flowers and hot dog buns, which were placed on resident plates. This action was contrary to the facility's policy and was confirmed during an interview with the Food Service Director, who acknowledged the importance of avoiding contamination of ready-to-eat food with contaminated gloves.
Failure to Obtain Psychotropic Informed Consent
Penalty
Summary
The facility failed to obtain a signed psychotropic informed consent for a resident diagnosed with bipolar disorder and schizophrenia. The resident, who was admitted in June 2024, has a severe cognitive impairment as indicated by a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS) and has a court-appointed guardian. The medical record review showed that the resident was receiving Lithium Carbonate, a medication for bipolar disorder, since June 21, 2024. However, the psychotropic consent form was undated and lacked the signature of the resident's representative or healthcare representative. During an interview, the Director of Nursing stated that attempts to contact the healthcare proxy and guardian had been unsuccessful, and the facility continued to administer the medication without consent, citing potential harm if the medication was stopped.
Failure to Maintain a Clean and Odor-Free Environment
Penalty
Summary
The facility failed to provide a clean and comfortable homelike environment for a resident, who was admitted with diagnoses including cerebral infarction and diabetes. The resident, who is cognitively intact and dependent on assistance for activities of daily living and toileting, reported a persistent strong odor in their room, which was confirmed by surveyor observations on multiple occasions. The resident expressed dissatisfaction with the cleanliness of the room, particularly while eating meals. The deficiency was linked to the management of the resident's incontinence care using a purewick system. The facility did not document the maintenance of the purewick system as ordered by the physician, which included changing the catheter head every 12 hours and cleaning the system components. Interviews with staff revealed that the room was cleaned daily, but the last deep cleaning occurred weeks prior, and there was no request to increase cleaning frequency despite awareness of the odor issue. The Unit Manager and Director of Nurses acknowledged the odor problem, attributing it to the purewick system's maintenance needs.
Failure to Resolve Grievance Regarding Staff Sleeping on Shift
Penalty
Summary
The facility failed to resolve a grievance filed by a resident regarding staff members sleeping during their shift. According to the facility's Grievance Policy, upon receiving a written grievance, the grievance officer is required to refer it to the appropriate department head for investigation, who must then submit a written report of findings within 72 hours. The grievance officer or designee is also responsible for informing the complainant of the findings and actions taken within 3-5 working days. However, a review of the grievance log revealed that a grievance was filed concerning staff sleeping during the 11-7 am shift, but there was no documented resolution on the grievance form. During an interview, the Director of Nursing acknowledged that a resolution should have been documented and mentioned that audits were conducted after the grievance was filed, but no documentation of resolution was provided.
Failure to Assess Mattress Bolsters as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of mattress bolsters as a potential physical restraint for a resident with severe cognitive impairment. The resident, admitted in May 2023 with diagnoses including cognitive communication deficit and chronic kidney disease, was observed with mattress bolsters placed under the fitted sheet at both the head and foot of the bed. These bolsters were intended to prevent the resident from climbing out of bed, as noted by the Certified Nurse Aides (CNAs) who stated that the resident frequently attempted to get out of bed despite being unable to stand. The facility did not conduct a restraint assessment to determine if the mattress bolsters limited the resident's freedom of movement, nor was there a physician's order or care plan documentation for their use. Interviews with staff, including a CNA, Unit Manager, and Regional Clinical Director, confirmed the absence of a formal assessment, although there was an informal discussion among the team regarding the use of bolsters. The lack of a documented assessment and physician's order constitutes a deficiency in ensuring the resident's freedom from unnecessary restraints.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse for three residents, which is a violation of their policy on abuse and neglect. Resident #55, who has intact cognition, filed a grievance after a nurse made a derogatory comment about them being 'drugged up.' Resident #DC1, with moderate cognitive impairment, reported that a certified nursing aide made a hurtful comment about their spouse not wanting to visit. Resident #78, who has severe cognitive impairment and is dependent on staff for care, had a representative report that certified nursing aides were rough in handling and instructed the resident to relieve themselves in their bed or brief instead of assisting them to the bathroom. The Social Worker, responsible for filing grievances, stated that she would notify the Director of Nursing if she believed an incident rose to the level of abuse. The Director of Nursing confirmed that allegations of abuse require an investigation and a report to the state agency within two hours. However, a review of the Healthcare Facility Reporting System showed that none of these allegations were reported to the state agency, indicating a failure to follow the required protocol for reporting potential abuse cases.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse for three residents, as required by their policies. Resident #55, who has intact cognition, filed a grievance after a nurse made a derogatory comment about them being 'always drugged up.' Resident #DC1, with moderate cognitive impairment, reported that a certified nursing aide made a hurtful comment about their spouse not wanting to visit. Resident #78, who is severely cognitively impaired and dependent on staff for care, had a representative report that certified nursing aides were rough in handling and instructed the resident to relieve themselves in their bed or brief instead of assisting them to the bathroom. The facility's policies require immediate notification and investigation of any grievances that rise to the level of potential abuse, neglect, or misappropriation. However, the facility did not provide any internal investigations for these allegations. Interviews with the Social Worker and Director of Nursing confirmed that allegations of abuse should trigger an investigation and reporting to the state agency, but this process was not followed for the grievances filed by the three residents.
Inaccurate MDS Assessment for Catheter Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately completed for a resident, leading to a deficiency. Specifically, the MDS for a resident inaccurately documented the use of an indwelling catheter. The resident, admitted in August 2021 with diagnoses including cerebral infarction and diabetes, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS assessment dated 9/5/24 incorrectly indicated the use of an indwelling catheter, while the medical record and physician's orders specified the use of a purewick catheter, which is an external catheter and not an indwelling one. Interviews with the Unit Manager and the Director of Nursing confirmed the inaccuracy in coding the purewick catheter as an indwelling catheter on the MDS.
Failure to Implement Orthotic for Contracture Management
Penalty
Summary
The facility failed to implement an orthotic for contracture management for a resident who was admitted with diagnoses including stroke and hemiplegia. The resident, who had a severe cognitive impairment as indicated by a BIMS score of 1 out of 15, was dependent on staff for activities of daily living and had a right upper extremity contracture. The physician's orders specified that a resting hand splint should be worn nightly and removed during the day as tolerated. However, observations on multiple occasions revealed that the resident was not wearing the orthotic, and it was not present in the room. During an observation, the Unit Manager confirmed the physician's order for the orthotic and noted that nursing staff would document if the resident refused to wear it. Despite this, a review of the nursing notes showed no indication of refusal by the resident. The Director of Nursing stated that all orders are expected to be followed as written, yet the orthotic was not being utilized as prescribed, indicating a failure in adhering to the care plan for the resident's contracture management.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to adhere to the wound care recommendations provided by the Wound Physician for a resident with an unstageable pressure wound on the right heel. The resident, who has a history of diabetes, diabetic neuropathy, and osteomyelitis, was observed multiple times with their right foot lying directly on the bed, contrary to the physician's orders to float the heels and use pressure off-loading boots. Despite the presence of a heel protecting bootie, it was found on a chair next to the bed rather than being used on the resident's foot. Additionally, the air mattress, which is part of the wound management protocol, was set at 325 pounds, not adjusted to the resident's actual weight of 150 pounds. Interviews with the nursing staff and the Director of Nursing confirmed that the resident should have been wearing heel protective booties at all times and that the air mattress should be set to the resident's weight for optimal wound healing. The Director of Nursing also mentioned that if the resident refused the interventions, a note of refusal should be documented, which was not indicated in the report. These observations and interviews highlight the facility's failure to implement the prescribed wound care interventions, potentially impacting the resident's wound healing process.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received respiratory care and treatment according to professional standards of practice and in accordance with physician's orders. The deficiency involved a resident with diagnoses including heart failure and chronic respiratory failure with hypercapnia. The resident's physician had ordered oxygen therapy at a flow rate of 1-2 liters per minute (LPM) to maintain oxygen saturation above 90%. However, observations by the surveyor on multiple occasions revealed that the resident's oxygen concentrator was set at four LPM, which was above the prescribed range. A family member of the resident confirmed that the oxygen had been set at four LPM, although it should have been at two LPM according to the physician's order. A nurse later adjusted the oxygen flow to the correct setting of two LPM. The Director of Nursing acknowledged that physician's orders should be followed and noted that setting the oxygen above the ordered range could lead to adverse effects, including circulation issues and imbalanced carbon dioxide levels.
Failure to Develop Comprehensive Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically PTSD. The resident, who was admitted with diagnoses including major depression, anxiety, and PTSD, was moderately cognitively impaired. The care plan initiated for the resident included general interventions such as encouraging the resident to speak up about uncomfortable situations and establishing a rapport to gain trust. However, it lacked specific triggers and individualized interventions related to the resident's PTSD diagnosis. The facility's policy on trauma-informed care, dated March 2019, outlines the need for staff to be trained in identifying triggers associated with re-traumatization. Despite this, the social worker was unaware of the resident's PTSD diagnosis and acknowledged that it should have been addressed in the care plan with specific triggers. Additionally, the psychiatric medication evaluation and psychotherapy notes for the resident did not include the PTSD diagnosis, indicating a gap in the documentation and care planning process.
Failure to Identify Medication Irregularity in Resident's Drug Regimen
Penalty
Summary
The monthly medication review (MRR) conducted by a licensed pharmacist failed to identify an irregularity in the drug regimen of a resident, who was receiving double the prescribed dose of Torsemide. This oversight occurred despite the facility's policies and procedures that require a thorough review of each resident's medication regimen. The resident, who was admitted with a diagnosis of heart failure, had two active physician's orders for Torsemide, each prescribing a 40 mg dose to be administered in the morning for different conditions. The Medication Administration Record (MAR) indicated that both doses were scheduled and administered at different times in the morning, leading to the resident receiving a total of 80 mg of Torsemide daily. The deficiency was identified during a review of the MRR dated 9/30/24, which failed to report the irregularity in the resident's Torsemide orders. Interviews with the Director of Nursing (DON) and the Regional Clinical Director confirmed that the expectation was for the MRR to recognize and report such discrepancies. The resident's moderate cognitive impairment, as indicated by a BIMS score of 10 out of 15, further underscores the importance of accurate medication management to prevent potential adverse effects.
Resident Receives Double Dose of Torsemide Due to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident receiving a double dose of Torsemide for 27 days. The resident, who was admitted with heart failure, had two separate physician orders for Torsemide: one for 40 mg in the morning for edema and another for 40 mg in the morning related to COPD with acute exacerbation. This led to the resident receiving 80 mg of Torsemide daily, which was not identified by the facility's medication administration processes or during the monthly medication review by the consultant pharmacist. The resident experienced significant weight loss and elevated BUN/creatinine levels, indicating potential kidney function issues. Despite the resident's weight loss and abnormal lab values, the facility's at-risk progress notes and physician's progress notes did not address the medication discrepancy. It was only upon review by a nurse and surveyor that the error was acknowledged, and the nurse practitioner was contacted to clarify the order. The Director of Nursing confirmed that the double dosing of Torsemide was a significant medication error, increasing the resident's risk for adverse effects.
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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