Plymouth Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth, Massachusetts.
- Location
- 123 South Street, Plymouth, Massachusetts 02360
- CMS Provider Number
- 225207
- Inspections on file
- 28
- Latest survey
- January 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Plymouth Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide a clean and homelike environment by not maintaining assistive devices for six residents. Observations showed issues like loose armrests and ripped seat backs on wheelchairs, and a resident had to tape their walker to prevent damage. Staff interviews revealed unclear processes for equipment maintenance, and the maintenance log lacked recent entries for the affected devices.
A facility failed to provide appropriate wound care for a resident with cysts on the elbow and thigh, as per the wound consultant's recommendations. Despite clear orders for specific dressings, treatments were not implemented, and medical records lacked documentation of necessary care. Miscommunication among staff led to the discontinuation of treatments, highlighting a lapse in adherence to professional standards and the resident's care plan.
A facility failed to provide necessary respiratory care for a resident by not administering oxygen at the correct flow rate, maintaining sanitary oxygen equipment, and ensuring a pulmonologist referral. The resident, with respiratory conditions, had orders for 2 L/min oxygen but was observed receiving 3-3.5 L/min. The BiPAP machine was not used as ordered, and no pulmonology appointment was scheduled, contributing to the deficiency.
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications by not attempting gradual dose reductions (GDRs). One resident on hospice services did not have a GDR attempted for antipsychotic medications despite no symptoms of psychosis. Another resident, cognitively intact and without behavioral changes, did not have a GDR attempted for olanzapine. A third resident on hospice, prescribed multiple psychotropic medications, also did not have a GDR attempted despite no behavioral issues. Staff interviews revealed a lack of awareness and evidence of GDR attempts.
The facility failed to maintain accurate medical records for four residents, as documentation of wound physician visits was not included in the medical records. A resident with traumatic brain injury and protein calorie malnutrition had missing wound physician notes, which were kept in the ICP's office. Another resident with a Stage IV pressure injury lacked documentation of wound physician visits for the past year. Additionally, a resident with large cysts and another with a pressure ulcer had missing wound care documentation in their medical records.
The facility failed to ensure consistent documentation of Advance Directives for two residents. One resident's physician's order did not match the court-ordered DNR/DNI status, while another resident's MOLST form was not reflected in the physician's orders, leading to discrepancies between the EHR and physical chart.
A resident developed an unstageable pressure ulcer, but the facility failed to notify the primary physician, leading to a delay in altering the treatment plan. The wound nurse did not document who was contacted, and the nurse practitioner and primary physician were unaware of the ulcer. The consultant wound physician's reports were sent to the wrong physician, resulting in a lack of proper documentation and awareness.
A facility failed to complete a required PASARR for a resident with bipolar disorder and alcohol abuse upon admission. The resident's medical records confirmed the active diagnosis, but no Level 1 PASARR was conducted by the facility. A social worker acknowledged the oversight, noting the only PASARR on record was from a previous facility in 2020.
A facility failed to develop and implement a care plan for a resident's BiPAP use, despite physician's orders and the resident's medical conditions requiring it. The resident, who was cognitively intact, reported not using the BiPAP machine, and a nurse confirmed the resident's refusal. The DON acknowledged the need for a care plan and documentation of the resident's refusal.
A facility failed to ensure proper care and treatment of a resident's PICC line, leading to a deficiency in IV fluid administration. The resident, with chronic osteomyelitis and Crohn's disease, required IV therapy for hydration. The facility did not obtain or implement physician's orders for PICC line care, including flushing, site assessment, and dressing changes. Observations revealed undated and improperly labeled IV equipment, and interviews confirmed inadequate documentation and adherence to policies.
A resident with chronic osteomyelitis and other conditions was incorrectly administered Fosfomycin daily instead of weekly due to an error in the Physician's Orders. The resident received the antibiotic daily for four days, contrary to the intended single weekly dose. The error was identified through a review of the Medication Administration Record, and interviews revealed a lapse in communication and verification of medication orders.
A resident with COPD and Diabetes was found to have unsecured medications, including Fluticasone nasal spray, a Trelegy inhaler, Calcium Carbonate tablets, and Diclofenac cream, on their overbed table. The resident self-administered these medications without an assessment for self-administration, and the DON was unaware of the unsecured medications, indicating a lapse in the facility's medication storage policy.
Facility Fails to Maintain Clean and Functional Assistive Devices
Penalty
Summary
The facility failed to maintain a clean and homelike environment for six residents on the [NAME] Unit by not providing properly maintained assistive devices such as wheelchairs and walkers. Observations revealed that several wheelchairs had issues such as loose armrests, ripped seat backs, and missing or damaged padding, which were not addressed in a timely manner. For instance, one resident's rolling walker had a cracked arm pad that was taped together, and another resident's wheelchair was labeled with a discharged resident's name, indicating a lack of proper maintenance and oversight. Interviews with staff and residents highlighted a lack of awareness and unclear processes regarding the maintenance and repair of assistive devices. A resident mentioned having to tape their walker to prevent further damage, while a nurse admitted to not knowing the procedure for routine repairs. Additionally, the maintenance log did not reflect any recent entries for the affected residents' equipment, suggesting a gap in the facility's system for tracking and addressing equipment issues. The Rehab Staff acknowledged the oversight and emphasized the need for immediate repair or replacement of the damaged equipment.
Failure to Implement Wound Care Treatments
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident, as per the recommendations of the wound consultant physician and the primary physician's treatment plan. The resident, who was cognitively intact, had a large cyst on the right elbow and thigh, which required specific wound care treatments. Despite the presence of clear orders from the consultant wound physician to apply specific dressings to the cysts, these treatments were not implemented as prescribed. The resident's medical records indicated a lack of documentation for the required treatments and monitoring of the cysts. The Treatment Administration Record showed that the prescribed treatments were not consistently followed, and there were no records of the necessary dressings being applied to the resident's wounds. Interviews with the nursing staff revealed a miscommunication regarding the implementation of the treatment orders, leading to the discontinuation of necessary care for the resident's wounds. The Assistant Director of Nurses and the Wound Nurse acknowledged the failure to implement the recommended treatments and the absence of weekly evaluations for the resident's wounds. The discontinuation of the treatment for the right elbow and the lack of implementation of the new treatment for the right thigh were attributed to miscommunication and oversight. This deficiency highlights a significant lapse in the facility's adherence to professional standards of practice and the resident's care plan.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, specifically in administering oxygen at the correct liter flow as per physician's orders, maintaining oxygen equipment in a sanitary manner, and ensuring the resident was referred to a pulmonologist. The resident, who was admitted with chronic obstructive pulmonary disease, pneumonia, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea, had a physician's order for continuous oxygen via nasal cannula at 2 liters per minute. However, observations revealed that the oxygen concentrator was set at 3 to 3.5 liters per minute, contrary to the physician's order. The resident's care plan included interventions for respiratory disease, such as assisting with repositioning for maximum airflow and monitoring oxygen saturation levels. Despite these interventions, the resident's oxygen tubing was not changed as frequently as ordered, and the BiPAP machine, which was supposed to be used at night, was not utilized by the resident. Interviews with nursing staff indicated a lack of adherence to the physician's orders, with discrepancies in the oxygen flow rate and the resident's refusal to use the BiPAP machine. Additionally, the facility did not schedule a pulmonology appointment for the resident, as indicated in the hospital discharge summary. The Director of Nursing confirmed that there was no documentation of a pulmonologist referral, which was necessary for the resident's ongoing respiratory care. This lack of follow-up and adherence to physician's orders contributed to the deficiency in providing appropriate respiratory care for the resident.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For Resident #1, the facility did not attempt a gradual dose reduction (GDR) of the antipsychotic medications risperidone and chlorpromazine, despite the resident being on hospice services and not exhibiting symptoms of psychosis. The Director of Nurses (DON) admitted that GDRs were not previously being attempted for residents on antipsychotic medication, and there was no evidence that a GDR was discussed or attempted for this resident in the past year. Resident #123 was admitted with diagnoses including visual hallucinations and dementia. Despite being cognitively intact and not exhibiting any signs of delirium or behavioral changes, the facility failed to attempt a GDR of the antipsychotic medication olanzapine since the resident's admission. Interviews with staff revealed uncertainty about the review or attempt of GDRs, and the DON confirmed that no evidence of a GDR attempt was available for this resident. Resident #87, who was on hospice services, was prescribed multiple psychotropic medications, including olanzapine and sertraline. Despite the resident not exhibiting any behaviors or changes in mood, the facility did not attempt a GDR in the previous 12 months. Observations noted the resident often sitting with their head on the table, and interviews with staff and family indicated a lack of awareness regarding the need for GDRs. The DON acknowledged that the resident had not been discussed at interdisciplinary team meetings for GDRs.
Failure to Maintain Accurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for four residents. Specifically, the documentation of wound physician visits was not included in the medical records in a timely manner. For Resident #58, who was admitted with diagnoses including traumatic brain injury and protein calorie malnutrition, the wound physician's notes were not found in the medical record. Instead, they were kept in a folder in the Infection Control Preventionist's (ICP) office, which was confirmed during an interview with the ICP. Resident #92, admitted in April 2021, had a Stage IV pressure injury and required specific wound care treatments. However, the medical record did not include any documentation of visits from the consultant wound physician for the past year. The Assistant Director of Nurses (ADON) confirmed that the wound physician's visit paperwork was kept in the ICP's office and not included in the resident's medical record. Similarly, Resident #79, admitted in October 2024, had large cysts on the right upper and lower extremities, but the medical record lacked documentation of current treatments or monitoring. The wound physician's visit notes were also missing from the medical record. Resident #90, who developed a pressure ulcer, had wound consultant visits documented in the ICP's office but not in the medical record. The ICP believed the consultant wound physician was uploading the visit summaries to the electronic medical record, but this was not the case.
Inconsistent Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the medical orders for Advance Directives were consistent with the court-ordered directives for two residents. For Resident #1, there was a discrepancy between the physician's order and the medical record regarding the resident's code status. Although the court had authorized the guardian to consent to a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, the physician's order indicated a full code status. Interviews with staff revealed that the information in the electronic health record (EHR) and the physical chart did not match, leading to confusion about the resident's actual code status. Similarly, for Resident #123, the facility did not update the physician's orders to reflect the resident's executed Advance Directives as indicated on the Massachusetts Order for Life Sustaining Treatment (MOLST) form. The MOLST form showed a DNR/DNI status, but the physician's orders incorrectly indicated a full code status. Staff interviews confirmed that the discrepancy between the physical chart and the EHR could lead to confusion during emergencies, as the orders did not accurately reflect the resident's current code status.
Failure to Notify Physician of Pressure Ulcer
Penalty
Summary
The facility failed to notify the primary physician about a new pressure ulcer on a resident, which was necessary to alter the treatment plan and prevent further deterioration. The resident, who was at risk for skin integrity issues due to conditions such as diabetes, developed an unstageable pressure ulcer on the coccyx. The initial treatment with triad paste was continued without proper documentation of physician verification. The wound nurse was unable to recall or document who was contacted regarding the ulcer, and the physician's orders were not updated until several days later. The resident's medical record did not include documentation from the consultant wound physician, and the primary physician and nurse practitioner were unaware of the pressure ulcer. The nurse practitioner, who was responsible for interim needs, discovered that staff were initiating treatment orders without physician verification. Additionally, the consultant wound physician's visit summaries were sent to the previous primary physician, not the current one, leading to a lack of awareness and documentation of the pressure ulcer by the responsible medical staff.
Failure to Complete PASARR for Resident with Mental Condition
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosed mental condition. The resident, admitted in January 2024, had diagnoses including bipolar disorder and alcohol abuse. A review of the resident's medical records, including a Psychiatric Evaluation and Consultation and a Minimum Data Set (MDS) assessment, confirmed the presence of bipolar disorder as an active diagnosis. However, the medical record did not indicate that a Level 1 PASARR was completed upon the resident's admission to the facility. During an interview, a social worker confirmed that the facility's social workers are responsible for completing the PASARR at the time of admission and acknowledged that the only PASARR in the record was from 2020, completed by another facility. The social worker also verified with the PASARR agency that no Level 1 PASARR was completed for the resident upon admission to the current facility.
Failure to Develop and Implement Care Plan for BiPAP Use
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident who required the use of a BiPAP machine. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, pneumonia, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea, was cognitively intact and had physician's orders for BiPAP use at bedtime. Despite these orders, the resident's care plan did not include any information regarding the use of the BiPAP machine. The deficiency was identified through observation, interview, and record review. The resident reported not using the BiPAP machine after their last hospitalization, and a nurse confirmed that the resident should be using the machine at night but had refused. The Director of Nursing acknowledged that a care plan should have been developed and implemented for the resident's BiPAP use, and that any refusal by the resident should be documented in their record and care planned.
Deficiency in PICC Line Care and Maintenance
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The resident, who was admitted with chronic osteomyelitis, resistance to Vancomycin, ESBL resistance, and Crohn's disease with fistulas, required IV therapy for hydration due to a high-output ostomy. Despite the critical need for IV therapy, the facility did not obtain or implement physician's orders for the care and maintenance of the resident's PICC line, including necessary procedures such as IV flushing, site assessment, dressing changes, catheter measurement, and arm circumference measurement. The facility's policies required specific orders for vascular access device flushing and detailed procedures for needleless connector changes, catheter dressing changes, and continuous medication administration. However, the resident's records lacked documentation of these essential care and maintenance activities. The Infusion Therapy Flowsheet was incomplete, with missing information on catheter length, arm circumference, and dressing changes. Additionally, there was no documentation of needleless connector changes, and the tubing change schedule was not adhered to, with several instances of missing site assessments. Observations by the surveyor revealed that the resident's PICC line dressing was undated and slightly lifted, and the IV bag and tubing were not labeled with a date and time. Interviews with nursing staff and the Director of Nursing confirmed the absence of proper documentation and adherence to facility policies. The Director of Nursing acknowledged that the resident's PICC information should have been included in the record and that nurses should have documented dressing changes, external catheter length, arm circumference, and needleless connector changes weekly.
Medication Administration Error: Fosfomycin Dosage Frequency
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Fosfomycin. The resident, who was admitted with chronic osteomyelitis, resistance to Vancomycin, ESBL resistance, and Crohn's disease with fistulas, was prescribed Fosfomycin as a prophylactic measure following a urinary tract infection. The After Visit Summary indicated that the resident should take Fosfomycin as a single dose, but the Physician's Orders mistakenly prescribed it as a daily dose. Consequently, the resident received Fosfomycin daily for four days instead of the intended single weekly dose. The error was identified during a review of the Medication Administration Record, which showed daily administration of Fosfomycin. Interviews with the Director of Nursing and the physician revealed that the order was entered incorrectly, and the physician was unavailable to verify the correct dosage frequency due to being on vacation. The physician later confirmed that Fosfomycin is typically dosed weekly, not daily, indicating a lapse in communication and verification of medication orders upon the resident's return from the hospital.
Unsecured Medications Found in Resident's Room
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely in accordance with professional principles. Specifically, for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Diabetes, medications including Fluticasone nasal spray, a Trelegy inhaler, Calcium Carbonate chewable tablets, and Diclofenac cream were found unsecured on the resident's overbed table. These observations were made on two separate occasions by the surveyor, indicating a lapse in adherence to the facility's medication storage policy. Interviews revealed that the resident self-administered these medications and refused to allow staff to remove them from the room. Nurse #1 acknowledged awareness of the situation but noted that the resident had not been assessed for self-administration of medications. The Director of Nursing was unaware of the unsecured medications, highlighting a communication gap and oversight in ensuring compliance with the facility's policy, which mandates that medications be stored in a locked cart or room accessible only to licensed nursing personnel.
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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