Parsons Hill Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 1350 Main Street, Worcester, Massachusetts 01603
- CMS Provider Number
- 225390
- Inspections on file
- 25
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Parsons Hill Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Three residents who were alert and oriented were discharged without being provided with the required Notice of Intent to Discharge, and the Office of the State Long-Term Care Ombudsman was not notified as mandated. Facility staff interviews confirmed that discharge notices and notifications were not issued for short-term stay residents, contrary to policy and regulatory requirements.
Several residents with complex medical needs reported that a CNA repeatedly treated them disrespectfully, including yelling, slamming items, and refusing assistance, leading residents to avoid seeking help from her. Staff interviews confirmed the CNA's rude and aggressive behavior, which was inconsistent with facility policy requiring respectful and dignified care.
The facility did not implement Consultant Pharmacist recommendations for three residents, despite physician agreement. This included failure to discontinue unnecessary supplements, update a Vitamin D3 regimen, and obtain a TSH lab test for a resident on levothyroxine. The DON confirmed that pharmacy recommendations were not consistently acted upon or documented by charge nurses.
Housekeeping staff failed to follow infection control protocols by wearing the same gloves while moving between resident rooms, handling trash, and cleaning equipment without performing required hand hygiene or changing gloves. This noncompliance with PPE and hand hygiene procedures was confirmed by both the staff member involved and the Infection Preventionist, despite annual training and competency assessments.
The facility failed to maintain an effective pest control program, resulting in ongoing rodent activity in multiple units and affecting several residents. Surveyors and residents observed live mice and droppings in rooms, and there was a documented lapse in exterminator services due to non-payment. Despite a pest control plan requiring bi-weekly visits, traps were missing or not in place, and concerns raised in Resident Council meetings were not communicated to maintenance, leading to unresolved pest issues.
A resident with anxiety and depression was administered Clonidine for anxiety without documented informed consent, as required by facility policy. The record lacked evidence that the purpose, dosage, risks, or benefits of the medication were discussed with the resident prior to administration, and staff confirmed the absence of the necessary consent documentation.
A resident with severe cognitive impairment was placed in a room with a large, unrepaired hole in the wall behind the bed, and exposed pipes were left protruding from a hallway wall after a water fountain was removed. Staff were uncertain if maintenance had been notified about the wall damage, and a nurse expressed concern about the safety risk posed by the exposed pipes after observing a resident interact with them.
A resident with a history of traumatic amputation and anxiety, who was cognitively intact and had a physician's order for ophthalmic care, did not receive vision services despite requesting and consenting to them. Facility staff were unaware of the signed consent, and the resident was not seen by vision consultants during multiple visits, resulting in unmet vision care needs.
A resident receiving tube feeding and water flushes via a G-tube was found to have unlabeled and undated enteral feeding and water bags in use, contrary to facility policy and physician orders. Multiple observations and staff interviews confirmed that required labeling—including resident name, date, time, formula, and nurse initials—was not present on the bags being administered.
A resident with COPD and chronic respiratory failure was repeatedly observed receiving oxygen at 1.5 LPM instead of the physician-ordered 2 LPM. Despite clear orders and facility policy, the oxygen concentrator was not set correctly until the issue was identified by surveyors and confirmed by nursing staff.
The facility did not consistently communicate or document required information with the dialysis center for two residents receiving hemodialysis, as mandated by facility policy. Communication forms detailing vital signs, medications, and changes in condition were not completed or sent prior to dialysis sessions, and staff confirmed this was not routine practice unless an issue arose.
A resident with a legal guardian did not receive a paper copy of the Notice of Medicare Non-Coverage (NOMNC) as required. Instead, facility staff only emailed the NOMNC to the guardian and did not mail a paper copy, contrary to CMS guidelines. The staff member responsible was unaware of the requirement to provide a paper copy.
Two residents had inaccurate MDS assessments: one was incorrectly coded as using an external catheter based on CNA documentation, despite no evidence of use, and another was not coded for receiving a prescribed antidepressant, even though it was administered daily. These errors were identified through record review and staff interviews.
A facility with 148 residents failed to ensure the DON did not serve as a charge nurse when occupancy exceeded 60 residents. The DON worked a night shift as a charge nurse due to staffing shortages, as confirmed by the ADON and the administrator. This was contrary to the DON's primary role of overseeing the Nursing Services Department to maintain quality care.
A facility failed to maintain accurate medical records for a resident requiring supervision with eating. Despite the care plan indicating supervision was needed, CNAs documented the resident as independent. The CNA Care Card was incomplete, missing crucial information on nutrition and required assistance. CNAs relied on verbal information or the incomplete care card, leading to inaccurate documentation.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required Notices of Intent to Discharge to three of four sampled residents prior to their discharge, as well as failed to notify the Office of the State Long-Term Care Ombudsman of these discharges. Specifically, documentation was lacking for residents who were alert, oriented, and had no cognitive impairment, as evidenced by their BIMS scores. The records for these residents did not contain the mandated written notification of discharge, nor did they show that copies of these notices were sent to the Ombudsman, as required by facility policy and state regulations. Interviews with facility staff revealed that the Director of Social Services had not been issuing discharge notices or notifying the Ombudsman for short-term stay residents. The Administrator also stated unawareness of the requirement to provide such notices and notifications for short-term residents. The deficiency was identified through review of medical records, progress notes, and facility policy, which outlined the necessary steps and information to be included in discharge notifications.
Failure to Treat Residents with Dignity and Respect by CNA
Penalty
Summary
Multiple residents reported that a Certified Nurse Aide (CNA) consistently treated them in a manner lacking respect and dignity. Residents described the CNA's behavior as rude, aggressive, and demeaning, with specific incidents including yelling, slamming items onto bedside tables causing spills, and refusing to assist with care needs. Several residents stated they avoided asking this CNA for help due to fear or discomfort, and some reported that their requests for assistance were met with hostility or outright refusal. The facility's own policy requires that residents be treated with consideration, respect, and full recognition of their dignity and individuality. Despite this, interviews and written statements from cognitively intact residents revealed a pattern of negative interactions with the CNA, including being yelled at for requesting basic care such as additional milk or assistance with a bedpan. Other staff members corroborated these accounts, noting that the CNA was rough, abrupt, and had to be redirected for her behavior multiple times. The issue was initially identified during a resident council meeting, where concerns about the CNA's conduct were raised. Subsequent interviews conducted by the Director of Social Services confirmed multiple complaints from residents about the CNA's disrespectful and aggressive behavior. The facility's internal investigation determined that the CNA's actions were inconsistent with standards for care and professionalism, and the matter was escalated from a customer service issue to a reportable incident after further review.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were implemented as required for three residents. In each case, the Consultant Pharmacist's recommendations were reviewed and agreed upon by the attending physician, but the recommended changes were not carried out in a timely manner. The facility's policy requires that consultant findings and recommendations be documented, communicated to the physician, and that the physician's orders be updated accordingly, but this process was not followed. For one resident with a history of gastrostomy, dysphagia, and malnutrition, the pharmacist recommended discontinuing a multivitamin and calcium supplement to reduce polypharmacy. Although the physician agreed, these medications continued to be administered for over five months before being discontinued. Another resident with alcohol abuse, hyperlipidemia, and chronic hepatitis C was recommended to switch from daily to monthly Vitamin D3 administration for convenience and efficiency. Despite physician agreement, the daily regimen continued for several months before the change was made. A third resident, who was prescribed levothyroxine for hypothyroidism, was recommended to have a TSH lab test to monitor therapy effectiveness. The pharmacist's recommendation was reviewed, but the TSH test was not completed, nor was there evidence that the recommendation was discussed with the physician. Interviews with the DON revealed that pharmacy recommendations were not consistently implemented, as charge nurses were responsible for ensuring follow-through but did not update resident records or obtain necessary orders.
Failure to Adhere to Infection Control Standards by Housekeeping Staff
Penalty
Summary
Housekeeping staff on the Greendale Unit failed to adhere to established infection control standards, specifically regarding the use of personal protective equipment (PPE) and hand hygiene. Observations revealed that a housekeeper wore the same pair of gloves while walking down the hallway, carrying trash bags, opening doors, and entering and exiting resident rooms without removing gloves or performing hand hygiene as required by facility policy. The housekeeper also handled cleaning equipment and interacted with another staff member while still wearing contaminated gloves, and re-entered a resident room without performing hand hygiene after glove removal. Interviews with the housekeeper and the Infection Preventionist confirmed that the observed actions were not in compliance with facility policies and training. The housekeeper acknowledged not removing gloves or performing hand hygiene at appropriate times, citing the condition of the trash bag as a reason. The Infection Preventionist stated that all staff receive annual education and competency exams on proper PPE use and hand hygiene, and confirmed that the housekeeper's actions did not align with the training provided.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program on three out of five units, directly impacting nine residents. Surveyors observed live mice in resident rooms and noted the absence of sticky pads or mouse traps in several rooms where residents reported frequent mouse sightings. Residents described seeing mice nightly or daily, and some had to store food in locked plastic bins to prevent attracting pests. Surveyors also observed mouse droppings and live mice caught in traps, indicating ongoing rodent activity within the facility. Despite the facility's pest control plan indicating bi-weekly exterminator visits, exterminator services were suspended for two months due to non-payment, and pest issues related to mice remained unresolved during this period. The exterminator confirmed he had not visited the facility since December, and the front desk staff corroborated this gap in service. Maintenance logs for the affected units did not document any concerns about rodents or pests during the time exterminator services were suspended, even though residents continued to report and observe mice. Resident Council meeting minutes from January and February documented ongoing concerns about mice in resident rooms, issues with food storage, and clutter, but these concerns were not communicated to maintenance for follow-up. During interviews, residents consistently expressed concern about the persistent presence of mice, and staff confirmed that while traps and locked bins were provided, the problem persisted. The facility's own quality improvement documentation acknowledged the ongoing pest issue, but the lack of consistent exterminator services and incomplete documentation of pest sightings contributed to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was fully informed and provided with necessary information to make health care decisions regarding the use of a psychotropic medication. Specifically, the facility did not obtain informed consent prior to administering Clonidine, prescribed for anxiety, to a resident who was cognitively intact and had diagnoses of Major Depressive Disorder and Anxiety Disorder. The resident's clinical record did not contain documentation that the purpose, dosage, risks, or benefits of Clonidine were discussed with the resident before the medication was given. Review of facility policy indicated that informed written consent for psychotropic medications must include information about the medication's purpose, dosage, and known effects or side effects. Despite this policy, the resident's record lacked evidence of such consent, and facility staff confirmed during interviews that the required informed consent documentation was missing for the administration of Clonidine for anxiety.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Wall Damage and Exposed Pipes
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by two specific deficiencies. In one instance, a resident with severe cognitive impairment, including dementia and schizophrenia, was observed in a room with a large hole in the wall behind the headboard of the bed. The resident had been moved into the room a few weeks prior, and the hole was reportedly caused by a previous occupant. Nursing staff were unsure if maintenance had been notified about the damage, indicating a lack of clear communication or follow-up regarding environmental concerns. Additionally, on the Burncoat Unit, exposed pipes were observed protruding from a hallway wall following the removal of a drinking fountain. A resident was seen grabbing onto these pipes, and a nurse had to intervene to redirect the resident away from the hazard. The nurse acknowledged that the exposed pipes were unsafe and expressed concern that a resident could be injured by falling onto them. These observations demonstrate lapses in the facility's responsibility to promptly address environmental hazards and maintain a safe setting for residents.
Failure to Coordinate Vision Care Services for Resident
Penalty
Summary
The facility failed to coordinate and provide vision care services for one resident who had requested and consented to such care. The resident, admitted with a history of traumatic amputation and adjustment disorder with anxiety, had a physician's order for ophthalmic care as needed and had signed a request for eye care services. Despite being cognitively intact and expressing a need for glasses for both distance and reading, the resident had not received an eye care appointment or been seen by vision consultants since admission. Interviews with facility staff revealed that the Director of Nursing was unaware of the signed consent for vision services, and the Assistant Director of Nurses confirmed that the resident had not been seen by vision consultants over the past year, despite multiple visits from the consultants to the facility. Documentation showed that the resident's request and physician's order for vision care were not acted upon, resulting in the resident not receiving necessary vision services.
Failure to Label Enteral Feeding and Water Flush Bags
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident who was receiving nutrition and hydration via a gastrostomy tube. Despite having clear physician orders and a facility policy requiring that all enteral feeding and water flush bags be labeled with the resident's name, date, time, formula, and nurse initials, observations on multiple occasions revealed that the bags in use for this resident were not labeled or dated. Both the enteral feeding formula (Jevity 1.5) and water flush bags were found hanging on the resident's feeding pump pole without any identifying information, and this was confirmed by both direct observation and staff interviews. The resident involved was cognitively intact and had diagnoses including gastrostomy status, dysphagia, and mild protein calorie malnutrition. The resident received the majority of their calories and fluids through the feeding tube, as documented in the medical record and physician orders. Nursing staff, including the day shift nurse and the DON, acknowledged during interviews that the labeling procedure was not followed, despite the facility's policy and the availability of labeling stickers. The deficiency was identified through observation, record review, and staff and resident interviews.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident diagnosed with COPD and chronic respiratory failure. The resident had a physician's order for continuous oxygen therapy via nasal cannula at 2 liters per minute (LPM). However, during multiple observations on different days, the resident was found receiving oxygen at 1.5 LPM instead of the prescribed 2 LPM. The resident was cognitively intact and aware that the oxygen should be set at 2 LPM, as confirmed during an interview. Facility policy and the American Association for Respiratory Care (AARC) guidelines require that oxygen be administered according to physician orders and that equipment settings be checked at least daily. Despite these requirements, the oxygen concentrator was repeatedly observed set incorrectly at 1.5 LPM. Nursing staff confirmed that the oxygen should have been set at 2 LPM per the physician's order, and the discrepancy was only corrected after it was brought to their attention during the survey.
Failure to Maintain Required Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for residents requiring renal dialysis. Specifically, the facility did not maintain ongoing communication or documentation with the dialysis center for two residents who were receiving regular hemodialysis treatments. Facility policy required that a communication form be completed prior to each dialysis treatment, including vital signs, medication records, and any changes in condition, and that this information be shared with the dialysis center. However, for both residents, there was no evidence that these forms were completed or that any communication was sent to the dialysis center for several months. One resident, admitted with chronic kidney disease and other related diagnoses, had a care plan and physician's orders specifying regular dialysis sessions and the need for communication with the dialysis center. Despite this, the resident's communication book contained only blank forms, and staff interviews confirmed that communication was not routinely provided unless there was a specific issue. The Assistant Director of Nurses acknowledged that required information such as vital signs and weights was not being communicated prior to dialysis appointments. A second resident, admitted with end stage renal disease and other conditions, also had a care plan and physician's orders requiring ongoing assessment and communication with the dialysis center. Review of records showed that communication forms were only completed on two occasions over a three-month period, with no ongoing documentation or communication as required. Staff interviews confirmed that the facility's practice was to only complete communication forms if there was a problem, rather than for every dialysis session as outlined in policy.
Failure to Provide Required Paper Copy of NOMNC to Resident's Guardian
Penalty
Summary
The facility failed to provide a paper copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's legal guardian as required by Centers for Medicare and Medicaid Services (CMS) guidelines. According to the instructions for the NOMNC, beneficiaries or their representatives must receive a paper copy of the notice, even if an electronic version is delivered. In this case, the facility staff only emailed the NOMNC form to the resident's guardian and did not mail a paper copy, as confirmed by both documentation review and staff interview. The resident involved was not self-responsible and had a legal guardian. The resident received Medicare Part A skilled services, which ended on a specified date. Facility records showed that the responsible party was notified by phone and email, but there was no evidence that a paper copy of the NOMNC was mailed as required. The staff member responsible for this process stated she was unaware of the need to mail a paper copy and had only emailed the form.
Inaccurate MDS Coding for Catheter Use and Antidepressant Administration
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents out of a sample of 29. For one resident with diagnoses including HIV, chronic hepatitis, and opioid dependence, the MDS was incorrectly coded to indicate use of an external catheter during the observation period, despite no evidence in the clinical record or direct observation that such a device was used. This error was traced to Certified Nurses Aides (CNAs) documentation, where an external catheter was incorrectly checked off, leading to the inaccurate MDS coding. For another resident with PTSD and anxiety disorder, the MDS assessment did not reflect the use of an antidepressant medication, Trazodone, which was prescribed and administered daily as per physician orders. The omission was confirmed during an interview with the MDS nurse, who acknowledged that the antidepressant should have been coded on the MDS but was not. Both deficiencies were identified through record review and staff interviews, with direct reference to the requirements outlined in the CMS RAI User's Manual.
DON Served as Charge Nurse Due to Staffing Shortage
Penalty
Summary
The facility, with an in-house census of 148 residents, failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit when the daily occupancy rate exceeded 60 residents. According to the facility's job description for the Director of Nursing Services, the primary purpose of the position is to oversee the Nursing Services Department to maintain the highest degree of quality care. However, a review of the Nursing Daily Schedule revealed that the DON worked as a charge nurse during the night shift from 11:00 P.M. to 7:00 A.M. This occurred because the facility was short-staffed, and the Assistant Director of Nurses (ADON) had already worked three night shifts that week, necessitating the DON to cover the shift. The facility's administrator confirmed the staffing shortage as the reason for the DON's assignment as a charge nurse.
Incomplete Medical Records and Inaccurate Documentation for Resident's Eating Supervision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required supervision with eating. The resident, admitted in June 2024, had a history of mitral valve replacement, diabetes mellitus, and dysphagia, and was on a minced and moist diet with thin liquids. Despite the hospital discharge summary and comprehensive care plan indicating the need for supervision during meals, the CNA Care Card, which guides CNAs on individual care needs, was incomplete. Key sections such as nutrition, diet consistency, liquids, meal location, and the level of required staff assistance for eating were left blank. Certified Nurse Aides (CNAs) documented the resident as independent for eating on multiple occasions, contrary to the care plan. Interviews with CNAs revealed that they relied on verbal information from other staff or the incomplete CNA Care Card to determine the resident's care needs. The Director of Nurses acknowledged that the CNA Care Card should have been completed upon the resident's admission, and the CNA flow sheets should have accurately reflected the resident's need for supervision during meals.
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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