Premier Healthcare At Harrington House
Inspection history, citations, penalties and survey trends for this long-term care facility in Walpole, Massachusetts.
- Location
- 160 Main Street, Walpole, Massachusetts 02081
- CMS Provider Number
- 225536
- Inspections on file
- 16
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Premier Healthcare At Harrington House during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions was found on the floor after an unwitnessed fall, but the nurse did not assess the resident before moving them, failed to notify the physician, and did not initiate required neurological checks or complete a new fall risk assessment, contrary to facility policy. Supervisory staff were unaware of the incident until later, confirming that established protocols were not followed.
A resident with impaired mobility and a high risk for pressure ulcers developed a DTI on the heel that worsened due to the facility's failure to consistently assess the wound, implement physician-ordered offloading interventions, and maintain an updated care plan. Staff were unaware of the resident's need for offloading booties, and documentation did not accurately reflect the resident's care, leading to further deterioration of the wound.
The facility did not provide timely written notice to the State Agency regarding changes in the Administrator and DON, as required. The new Administrator and DON assumed their roles, but these changes were not updated in the state reporting system, and the responsibility to report was not fulfilled by either the current or previous management.
Surveyors identified failures in infection prevention and control, including missing infection surveillance logs, a non-specific water management plan, and improper cleaning and storage of G-tube, oxygen, nebulizer, and CPAP equipment. Multiple residents had medical devices and surrounding areas that were not kept clean or stored according to policy, and staff confirmed these practices did not meet infection control standards.
The facility did not maintain records or documentation of antibiotic use for several months, despite having a policy for an antibiotic stewardship program. Staff and the DON confirmed that antibiotic use records were unavailable for the requested periods, indicating a lack of monitoring and documentation as required.
Four residents did not have individualized, comprehensive care plans addressing their specific needs, including use of antipsychotic medications, smoking status, and CPAP therapy. Care plans lacked resident-specific targeted behaviors, non-pharmacological interventions, and measurable goals, despite staff and policy expectations.
Nursing staff failed to follow physician orders for tube feeding administration, dietary consults, hospital transfers, air mattress settings, and medication administration for several residents. This included not adhering to prescribed feeding schedules, not obtaining required consults or transfer orders, inaccurately documenting air mattress settings, and leaving medication at the bedside without administration or proper notification.
The facility failed to ensure that pharmacy consultant recommendations for two residents were communicated to the physician and addressed in a timely manner. One resident's medication reduction recommendation was not reviewed for eight months, and another resident's pharmacy recommendations regarding inhalation therapy orders were not accessible or acted upon for over 230 days due to record-keeping issues. These lapses resulted in delayed review and action on important medication regimen recommendations.
The facility did not provide two residents' legal representatives with the necessary information or opportunity to give informed consent for admission, treatment, or the use of side rails. In both cases, required consent forms were either left unsigned or completed without proper explanation, and staff interviews confirmed that the expected procedures for obtaining consent were not followed.
The facility did not notify the legal representatives of two residents about significant changes in their conditions, including the development of a deep tissue injury and a substantial weight loss. In both cases, required notifications to the guardian or HCP were not documented or made, as confirmed by staff and record reviews.
A resident with significant medical needs was admitted with a court-appointed legal guardian, but the facility did not involve the guardian in the baseline care plan process or provide a summary of the care plan as required. Staff and family interviews confirmed that neither the resident nor the guardian received or were offered the necessary documentation or participation in the initial care planning.
Two residents with significant cognitive impairment were placed on bed rails without documented attempts at alternative interventions, review of risks and benefits, or obtaining informed consent prior to installation. In both cases, required assessments and documentation were incomplete or missing, and staff confirmed that proper procedures for consent and education were not followed.
Two residents had medications and treatments left unattended in their rooms, including an anticoagulant pill for a resident with severe cognitive impairment and a medicated cream for a cognitively intact resident. Staff and DON confirmed that medications and treatments should not be left out and must be stored in locked compartments, but these protocols were not followed.
Three residents who had provided consent for pneumococcal vaccination did not receive the appropriate immunizations as required by facility policy and CDC guidelines. Despite having signed consent forms and being eligible, these residents were not administered the indicated vaccines, and staff confirmed the oversight during interviews.
Two residents who were eligible and had provided consent did not receive the COVID-19 vaccine or booster as required, and there was no documentation of vaccine administration despite multiple requests and inquiries. Staff confirmed that the vaccinations should have been given, but records and immunization registries did not show evidence of administration.
The facility did not accurately complete MDS assessments for two residents with psychiatric diagnoses, incorrectly coding them as having schizophrenia instead of schizoaffective disorder bipolar type. Additionally, another resident's discharge status was inaccurately recorded as a transfer to a hospital rather than a discharge home with services. The MDS Coordinator acknowledged these errors during interviews.
A resident with severe cognitive impairment and a history of stage 2 pressure ulcers had their wounds resolved and treatment orders discontinued, but the care plan was not updated to reflect the healing of the ulcers. Despite care plan meetings and facility policy requiring timely review and revision, the care plan continued to list the resolved wounds and interventions.
A resident with severe cognitive impairment was found in a Broda chair with restricted movement due to a couch placed against one side and a wall on the other. The resident required assistance for mobility and was at risk of falls. Staff interviews revealed that the couch was moved by a nurse during the night, but it was found in the same position again in the morning. The facility's policy is to be restraint-free, and the setup was deemed inappropriate.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Fall Assessment and Notification Protocol After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, adult failure to thrive, diabetes mellitus, and anemia was found on the floor after an unwitnessed fall. Facility policy requires that a licensed nurse assess any injuries before moving the resident, notify the supervisor and physician, complete a physical assessment, initiate neurological checks, and perform fall, skin, and pain assessments. However, the nurse who found the resident did not assess the resident prior to moving them, did not notify the physician, and did not initiate neurological checks or complete a new fall risk assessment as required by policy. The nurse also relied on assistance from CNAs to move the resident before conducting an assessment. Documentation in the medical record did not support that the required notifications and assessments were completed. The nurse supervisor and DON were unaware of the incident until after it occurred and confirmed that the facility's protocol was not followed. The failure to follow established procedures for assessment and notification after an unwitnessed fall resulted in the resident not receiving care and treatment that met professional standards of nursing practice.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with significant mobility impairments and a high risk for pressure ulcers developed a deep tissue injury (DTI) on the right heel, which was first identified by staff and evaluated by a wound physician. The wound physician recommended the use of offloading booties and scheduled follow-up, but after the facility's contract with the wound physician group ended, the resident did not receive further wound evaluations by a physician, nurse practitioner, or licensed nurse. There was no documentation of wound measurements or progress towards healing after the last wound physician visit, and the resident's wound was not assessed or monitored as required by facility policy. Despite active medical orders for offloading booties to be worn at all times, multiple observations by surveyors revealed that the resident was consistently found in bed without the booties or any offloading device in place. Interviews with nursing staff and CNAs indicated a lack of awareness regarding the resident's need for offloading booties, and the care Kardex did not reflect this requirement. The care plan for the resident did not include interventions for the right heel DTI, and nursing progress notes failed to consistently document the status and treatment of the wound. The Treatment Administration Record (TAR) was being signed off as if the booties were in place, but this was contradicted by direct observation and staff interviews. The resident's wound deteriorated from a dime-sized, intact area to a quarter-sized, open wound with drainage. The lack of consistent wound assessment, failure to implement and communicate care interventions, and absence of a care plan for the pressure injury contributed to the further deterioration of the resident's condition. The deficiency was further compounded by the lack of communication among staff and the absence of ongoing monitoring and evaluation of the wound after the departure of the wound care consultant.
Failure to Timely Report Changes in Administrator and DON to State Agency
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding changes in key administrative personnel, specifically the Administrator and Director of Nursing (DON). The new Administrator began her role on 3/10/25, and the new DON started on 3/15/25. However, these changes were not updated in the Health Care Facility Reporting System (HCFRS) as required. The last reported changes in the system were for the Administrator on 12/6/24 and for the DON on 5/23/24, with no indication that the previous individuals were no longer employed or that new personnel had assumed these roles. During interviews, the Administrator acknowledged that the changes were not yet reflected in the HCFRS and stated that the process was ongoing. It was revealed that the previous management company had indicated they would update the system but did not do so, and some staff from the prior company who still had access also failed to report the changes. Both the current Administrator and DON recognized that it was their responsibility to ensure the updates were made in the reporting system, but this was not completed as required.
Infection Control Program Deficiencies and Improper Equipment Storage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, environmental management, and equipment care. The facility was unable to provide completed infection surveillance logs for several months, despite policy requirements for ongoing, systematic collection and analysis of infection-related data. Interviews with support staff and the DON confirmed that surveillance logs prior to March were unavailable, indicating a lack of adherence to the facility's own infection surveillance policy. The facility's water management plan was found to be non-specific and inaccurate, with key elements such as the involvement of the Medical Director and accurate facility descriptions missing. The Director of Maintenance acknowledged that the plan did not reflect the actual facility layout or features, and the DON confirmed that the water management plan should have been tailored to the facility. This failure to maintain a facility-specific water management plan did not align with CMS guidance and the facility's own policies regarding Legionella risk reduction. Multiple residents were observed with medical equipment, including G-tube supplies, oxygen tubing, nebulizer masks, and CPAP machines, that were not maintained or stored in a clean and sanitary manner. For example, one resident's tube feeding equipment and surrounding area were repeatedly observed to be soiled with dried formula, and a piston syringe was left uncovered and outdated. Other residents had respiratory equipment such as oxygen tubing, nebulizer masks, and CPAP masks left exposed to the environment, undated, and not stored in protective bags as required by facility policy. Staff interviews consistently confirmed that these practices did not meet infection control expectations and that equipment should have been cleaned, dated, and stored properly.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. During the survey, the surveyor requested records of antibiotic use for three specific months, but facility staff were unable to provide documentation for those periods. Multiple interviews with support staff and the Director of Nursing confirmed that the facility did not have access to or could not produce the required antibiotic use records prior to March 1, 2025. The facility's policy indicated the intent to implement an antibiotic stewardship program, but there was no evidence of monitoring or documentation of antibiotic use as required.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for four residents, each with specific needs that were not adequately addressed. For one resident with bipolar disorder and severe cognitive impairment, the care plan for antipsychotic medication use did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment. Similarly, another resident with multiple psychiatric diagnoses and severe cognitive impairment was administered several psychotropic medications, but the care plans did not include non-pharmacological interventions, measurable goals, or address all prescribed medications. A third resident, who was a smoker with moderate cognitive impairment and required assistance with activities of daily living, did not have a care plan addressing their smoking status or preferences, despite facility policy requiring such plans for all residents who smoke. Interviews with staff confirmed that the resident participated in supervised smoking sessions and required protective equipment, but this was not reflected in the care plan. The Director of Nursing and other staff acknowledged that a care plan should have been in place for the resident's smoking status and any changes in their smoking behavior. The fourth resident, diagnosed with sleep apnea and using a CPAP machine nightly, did not have an interdisciplinary comprehensive care plan addressing the use of the CPAP device. Staff interviews confirmed that the resident used the CPAP machine as ordered, but no care plan was developed to outline measurable objectives, timeframes, or interventions related to the device. The lack of care plans for these residents was confirmed through record review and staff interviews, indicating a failure to meet facility policy and regulatory requirements for comprehensive, individualized care planning.
Failure to Follow Physician Orders and Professional Standards in Resident Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for multiple residents. For one resident with a feeding tube, nursing staff did not consistently administer tube feeding formula according to the physician's order, which specified the timing and duration of the feeding. Observations revealed that the feeding was not turned off and restarted at the prescribed times, and interviews with nursing staff confirmed lapses in following the order. Additionally, a physician-ordered dietitian consult for this resident was not completed or documented, despite ongoing weight gain and repeated orders for the consult. Another resident was transferred to the hospital on two occasions without a physician's order for the transfer, as required by facility policy. Review of the medical record and interviews with nursing staff and management confirmed that no orders were obtained or documented prior to these transfers, despite the expectation that such orders be secured and transcribed. For two other residents, the facility did not ensure that air mattress settings were maintained and documented according to physician orders. Observations showed that the air mattresses were set at levels different from those ordered, while the medical records indicated staff had signed off as if the correct settings were in place. In one case, a resident's medication was left at the bedside and not administered as ordered, with the nurse failing to notify the physician or supervisor of the missed dose. The medication administration record was inaccurately signed to indicate the medication had been given.
Failure to Timely Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) conducted by a licensed pharmacist were communicated to the physician and addressed in a timely manner for two residents. For one resident admitted with diagnoses including adult failure to thrive, abscess of the pharynx, and dysphagia, the consultant pharmacist recommended in June 2024 a possible reduction in Famotidine dosage. This recommendation was not addressed by the physician, and the Director of Nursing (DON) only contacted the attending practitioner eight months later, at which point the recommendation was declined without a documented rationale. The process for addressing MRR recommendations, which requires timely physician or nurse practitioner review and documentation of rationale for declined recommendations, was not followed in this case. For another resident with chronic obstructive pulmonary disease (COPD), pharmacy consultant notes indicated recommendations were made in August, September, and October 2024 regarding the need to clarify two as-needed orders for Duoneb. However, the facility was unable to locate these recommendations in the medical record, as they were stored in the previous owners' computer system. The recommendations were only addressed after the survey team requested them, resulting in a delay of over 230 days from the initial recommendation. This demonstrates a failure to ensure that pharmacy recommendations were accessible and acted upon in a timely manner.
Failure to Obtain Informed Consent from Resident Representatives
Penalty
Summary
The facility failed to ensure that resident representatives were provided with the necessary information and opportunity to exercise their rights regarding consent for treatment and services. For one resident with a court-appointed legal guardian, the facility did not provide or obtain signed or verbal consent for admission, treatment, or consultation with a wound care specialist. The legal guardian reported that the facility did not communicate with him about required consents, and a review of the medical record confirmed that these documents were left blank and unsigned. Multiple staff interviews confirmed that the expected process for obtaining consent was not followed, and there was no evidence that the legal guardian was given the opportunity to provide informed consent during the period of guardianship. For another resident with severe cognitive impairment and an activated health care proxy (HCP), the facility failed to obtain consent for treatment and the use of bilateral side rails at the time of admission. The HCP was only asked to sign the necessary paperwork several months after the resident's admission, and did so without any discussion or explanation from nursing staff regarding the risks and benefits of side rail use. The consent form for side rails was incomplete, with several required fields left blank, and the HCP stated that he was not informed about what he was signing. Staff interviews and record reviews indicated that the facility did not follow its own procedures for obtaining informed consent from resident representatives at the time of admission or prior to implementing specific treatments or interventions. The lack of communication and failure to provide information in advance prevented the resident representatives from exercising their rights as required.
Failure to Notify Legal Representatives of Significant Resident Condition Changes
Penalty
Summary
The facility failed to notify the legally responsible representatives of two residents regarding significant changes in their conditions, as required by facility policy. In the first case, a resident with a court-ordered temporary guardian developed a deep tissue injury (DTI) on the right heel, which was identified and evaluated by a wound physician. There was no documentation or evidence that the legal guardian was informed of the development of the pressure ulcer or the subsequent physician evaluation and new treatment orders. Interviews with the resident, family members, nursing staff, the unit manager, and the Director of Nursing confirmed that the legal guardian was not notified, despite being responsible for treatment decisions at the time. In the second case, another resident with severe cognitive impairment experienced a significant weight loss over a three-month period, which was documented in the medical record and noted as a clinical change. The resident's Health Care Proxy (HCP) was activated due to the cognitive deficit, but there was no evidence in the medical record that the HCP was notified of the weight loss. The HCP confirmed during an interview that they were unaware of the resident's weight loss. Nursing staff, the unit manager, and the Director of Nursing all reviewed the record and acknowledged the lack of documentation or notification to the HCP. The facility's policy requires prompt notification of the resident, physician, and legal representative or HCP in the event of significant changes in condition, such as the development of a pressure injury or significant weight loss. In both cases, the required notifications were not made or documented, as confirmed by staff interviews and record reviews.
Failure to Involve Legal Guardian in Baseline Care Plan and Provide Required Documentation
Penalty
Summary
The facility failed to involve a resident's legal guardian in the baseline care plan process and did not provide a copy of the baseline care plan summary within the required timeframe. According to facility policy, a baseline care plan must be developed within 48 hours of admission, and a written summary should be provided to the resident and their representative in a language they can understand. The summary should include initial goals of care, a summary of medications and dietary instructions, and any services or treatments to be administered. Documentation should also reflect that the summary was provided, either in person or by mail, and that the resident or representative acknowledged receipt. In this case, a resident with multiple diagnoses, including intracranial injury and mobility issues, was admitted with a court-ordered temporary guardian in place. The medical record did not show that the legal guardian was involved in the baseline care plan process or that a summary was provided or offered. Interviews with the resident, family members, and staff confirmed that neither the resident nor the legal guardian participated in the initial care plan meeting or received the required documentation. The facility's own staff acknowledged that the process for baseline care plans was not followed for this resident.
Failure to Obtain Informed Consent and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted prior to the installation of bed rails and did not review the risks and benefits of bed rails with the residents or their representatives, nor did it obtain informed consent prior to installation for two residents out of a sample of eighteen. According to the facility's own policy, a comprehensive assessment should be conducted to determine the need for bed rails, including consideration of alternatives, and informed consent must be obtained before use. However, for both residents involved, these steps were not followed as required. One resident, who had significant cognitive impairment and a temporary guardian, was observed multiple times with bilateral upper side rails in use. The medical record did not show documentation of alternatives attempted or a completed consent form, and there was no physician's order for the bed rails prior to their use. Staff interviews confirmed that consent and an order should have been obtained before the rails were installed, but this was not done. The resident's assessment also lacked documentation of alternatives attempted prior to installation. Another resident, also with severe cognitive impairment and an activated health care proxy, was observed with bilateral side rails in use. Although there was a physician's order for the rails, the consent form was not signed until many months after the rails were put in place, and key sections of the form were left blank. The health care proxy reported signing paperwork without any discussion of the risks and benefits of side rail use, and staff confirmed that informed consent and education should have occurred before the rails were installed, but did not.
Failure to Securely Store Medications and Treatments
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and not left unattended, as required by policy and professional standards. For one resident with severe cognitive impairment and a history of stroke, a medication cup containing a yellow pill was found left unattended on the overbed table. The resident was unable to identify the pill, and there was no documentation that the resident was assessed to self-administer medications. The nurse initially misidentified the pill and later confirmed it was Eliquis, an anticoagulant prescribed to the resident. The medication administration record indicated the medication had been given as ordered, but the pill was still present and unattended at the bedside. In a separate incident, another resident who was cognitively intact had a prescribed medicated cream, Silver Sulfadiazine, repeatedly observed left unattended on the nightstand over multiple surveyor visits. Interviews with nursing staff and the DON confirmed that medicated creams should not be left in resident rooms and must be stored in locked treatment carts. The resident reported that nurses applied the cream, but it was not removed from the room after use, contrary to facility policy and standard practice.
Failure to Administer Pneumococcal Vaccinations as Consented
Penalty
Summary
The facility failed to provide pneumococcal immunizations as requested or consented for three residents out of a sample of five. According to the facility's policy, all residents should be offered pneumococcal immunization in accordance with CDC guidelines, unless medically contraindicated or previously immunized. Each resident or their representative is to receive education about the vaccine, and a signed consent form is required before administration. However, record reviews and interviews revealed that three residents who had signed consent forms and were eligible for the vaccine did not receive the appropriate pneumococcal immunizations. Specifically, one resident admitted in September 2023 had no record of receiving the pneumococcal vaccine despite a signed consent. Another resident, admitted in October 2022, had previously received PCV13 but was overdue for the PCV20 vaccine, which was not administered despite consent. A third resident, admitted in November 2015, had received a pneumococcal vaccine in 2020 but was also overdue for the PCV20 vaccine, with a signed consent present in the record. Staff interviews confirmed that these residents should have received the indicated vaccines but did not.
Failure to Provide and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to provide education and/or offer the COVID-19 vaccination to eligible residents as required by CDC recommendations and the facility's own policy. Specifically, one resident admitted in September 2023 had a signed consent for the COVID-19 vaccine but no documentation of receiving the vaccine was found in either the Massachusetts Immunization Information System or the resident's medical record. Another resident, admitted in November 2015 and assessed as cognitively intact, reported not receiving the COVID-19 vaccine for the 2024/2025 season despite multiple requests and a signed consent form. The immunization history for this resident showed a previous COVID-19 vaccine administered in November 2023, but no record of the most recent booster being given. Interviews with facility staff confirmed that both residents should have received the COVID-19 vaccine or booster according to current guidelines and their signed consents, but there was no evidence of administration or proper documentation. Resident council minutes also indicated that residents were seeking information about the availability of the COVID-19 booster, suggesting a lack of communication and follow-through regarding vaccination efforts.
Inaccurate MDS Assessments for Diagnoses and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the true status of three residents. For two residents admitted with schizoaffective disorder bipolar type, their MDS assessments incorrectly documented a diagnosis of schizophrenia instead of their actual psychiatric condition. The MDS Coordinator acknowledged during interviews that the MDS assessments for these residents did not accurately represent their diagnoses, confirming that the coding was not done correctly. The Director of Nursing stated that his expectation was for all MDS assessments to accurately represent each resident's medical conditions. Additionally, for a third resident who was admitted with multiple injuries and fractures, the MDS assessment inaccurately recorded the resident's discharge status. Although the resident was discharged home with visiting nurse services, the MDS assessment indicated a discharge to a short-term general hospital. The MDS Coordinator confirmed this was an error after reviewing the resident's medical record and discharge documentation.
Failure to Update Care Plan After Pressure Ulcer Resolution
Penalty
Summary
The facility failed to review and revise the care plan for a resident after the resolution of two pressure ulcers. The resident, who had severe cognitive impairment and was at risk for pressure ulcers, was admitted with stage 2 pressure ulcers to the coccyx and right lateral dorsal foot. Although the wounds healed and corresponding treatment orders were discontinued, the care plan continued to list the pressure ulcers and related interventions without updating to reflect their resolution. Documentation showed that care plan meetings occurred after the wounds had healed, but no revisions were made to remove the resolved ulcers from the care plan. Review of the medical record indicated that the coccyx wound healed and the treatment order was discontinued, while the right lateral dorsal foot wound had its last assessment as a stage 3 ulcer before the treatment order was discontinued. There was no documentation of a final skin assessment confirming the healing of the foot wound. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not done in this case, resulting in an outdated care plan that did not accurately reflect the resident's current condition.
Resident Restrained by Improper Broda Chair Setup
Penalty
Summary
The facility failed to ensure that a resident, who was severely cognitively impaired and dependent on staff for all care, was free from restraints. On a specific date, the resident was found in the day room in a Broda chair that was fully reclined, with a couch placed against one side and the other side against the wall, restricting the resident's movement. This setup was identified by the Unit Manager, who questioned the appropriateness of the arrangement as it restricted the resident's freedom of movement. The resident had been admitted to the facility with diagnoses including dementia, a left femur fracture, coronary artery disease, and dysphagia. The resident's medical record indicated a physician's order for hospice care and the use of a Broda chair. The resident was assessed as severely cognitively impaired and required assistance from two staff members for mobility. The Unit Manager noted that the resident was at risk of falling due to weakness and an unsteady gait, and interventions for safety included the use of the Broda chair and positioning the resident where they were visible to staff. Interviews with staff revealed that the couch was placed against the resident's chair during the night shift. Nurse #1 found the couch against the chair earlier in the night and moved it, educating the CNAs on the inappropriateness of such an intervention. However, the couch was found in the same position again by the Unit Manager in the morning. Both CNAs denied placing the couch against the chair, and the resident was not capable of moving it themselves. The Director of Nurses confirmed that the facility's policy is to be restraint-free and that the placement of the couch was inappropriate and considered a restraint.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
