Prescott House
Inspection history, citations, penalties and survey trends for this long-term care facility in North Andover, Massachusetts.
- Location
- 140 Prescott Street, North Andover, Massachusetts 01845
- CMS Provider Number
- 225510
- Inspections on file
- 32
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Prescott House during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive prescribed doses of Diazepam and Debrox Otic Solution as ordered, and nursing staff failed to document the reasons for non-administration or actions taken, contrary to facility policy. The DON confirmed that proper documentation and physician notification were expected but not completed.
A resident with multiple chronic conditions did not receive physician-ordered CBC and BMP lab tests, as there was no documentation that the tests were ordered or obtained. Nursing staff did not follow up on the missing labs or notify the physician or NP, and facility policy requiring test processing and communication was not followed.
The facility failed to maintain a homelike environment on the A Unit, with issues such as chipped enamel on a bed frame, missing draw chains on window shades, unpainted plaster, and a dangling wired wall receptacle. These deficiencies were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a pacemaker lacked a detailed care plan, and fall prevention measures were not in place. Another resident with hemiplegia did not receive prescribed assistive devices, and a third resident with quadriplegia was not provided with a required hand roll. Staff were unaware of these lapses, and there was no documentation of resident refusal.
The facility failed to inspect and document bed entrapment zones, leading to potential safety risks. A bed bolster was improperly fitted, creating a significant gap. The previous Maintenance Director did not complete required checks, and the current Maintenance Director from another facility was tasked with completing them. The DON acknowledged the oversight and the incorrect bolster used, posing a risk of resident entrapment.
The call system on the A Unit was non-functional, with call bells not sounding or illuminating at the nursing station. Many residents were unaware of the issue and continued using the call bell, leading to delayed responses. Some residents lacked hand bells, and those provided were often out of reach. Staff were aware of the malfunction since November 2024, but repairs were not made, and hand bells were not consistently distributed.
A resident with limited hand function and multiple health issues was not consistently provided with necessary assistance during meals, leading to an undignified dining experience. Despite the facility's policy, staff failed to offer help with opening lids or cutting food, leaving the resident to manage independently. The unit manager acknowledged the oversight, attributing it to a new meal distribution system and staff unfamiliarity with resident needs.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. A resident with an ulcer did not have their wound dressing changed for three days, contrary to daily change orders. Another resident requiring continuous oxygen had their tubing unchanged for three weeks, with no schedule in place. Documentation errors and misunderstandings among staff contributed to these issues.
A resident with multiple medical conditions requiring assistance with meal setup did not receive consistent help from staff, leading to difficulties in managing meals independently. The resident's care plan indicated a need for setup and cleanup assistance, but staff often left meal trays without offering help. A unit manager cited a new meal distribution system and staff learning curve as reasons for the oversight.
A resident dependent on renal dialysis experienced repeated bleeding at the fistula site, but the facility failed to document the catheter location, dressing condition, or post-dialysis observations. There was no communication with the dialysis center or notification to the practitioner about the bleeding, contrary to facility policy and physician orders. Observations showed undated and uninitialed dressings, and interviews confirmed the lack of required documentation and communication.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. One resident with hemiplegia was documented as wearing a splint and wedge, but observations showed otherwise. Another resident with quadriplegia was documented as wearing a hand roll, contrary to observations. A third resident with a toe ulcer had inaccurate dressing change documentation. Staff interviews confirmed the need for accurate documentation.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically an anxiolytic (Diazepam) and an ear drop medication (Debrox Otic Solution). According to the Medication Administration Record (MAR), the resident did not receive the prescribed doses on multiple occasions, and the nurse documented a code indicating 'other, see nursing note.' However, there was no documentation in the nurse's progress notes explaining why the medications were not administered or what actions were taken in response to the missed doses. This lack of documentation was in direct contradiction to the facility's policy, which requires nurses to document the reason for withholding medication and any subsequent steps taken, as well as to notify the physician if a medication is refused or withheld two or more consecutive times. The resident involved had multiple diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block status post pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness. Despite the nurse's acknowledgment during interview that she was responsible for administering the medications and should have documented the reasons for non-administration, she was unable to recall why the medications were not given or why documentation was not completed. The Director of Nursing confirmed that the expectation is for nurses to document the reason for missed medications and notify the physician, which was not done in this case.
Failure to Provide Ordered Laboratory Services and Notify Medical Staff
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block with pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness, was admitted to the facility. The physician ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be drawn on a specific date. However, there was no documentation that these laboratory tests were ordered or obtained as directed by the physician. Review of the resident's Medication Administration Record (MAR) and interviews with facility staff revealed that the laboratory tests were not completed, and there was no evidence that nursing staff followed up on the missing tests or informed the physician or nurse practitioner of the omission. The nurse practitioner noted in the progress note that the laboratory results were pending, but was not aware that the tests had not been drawn or the reason for the delay. Nursing staff involved in the admission process could not explain why the orders for the CBC and BMP were not processed, and the unit manager and DON confirmed that there was no documentation to support that the tests were ordered or that follow-up occurred. Facility policy required that staff process test requisitions and arrange for laboratory services as ordered by the physician, and that nurses follow up on pending or missing results. In this case, the required laboratory services were not provided, and there was a lack of communication and documentation regarding the failure to obtain the ordered tests and notify the appropriate medical staff.
Failure to Maintain Homelike Environment on A Unit
Penalty
Summary
The facility failed to ensure a homelike environment on the A Unit, as observed by the surveyor on 1/21/25. Several deficiencies were noted, including a bed frame with approximately 12 inches of chipped enamel, missing draw chains on window shades in two rooms, unpainted and unsanded plaster on a bedroom wall measuring approximately 13 x 6 inches, and a dangling wired wall receptacle with exposed wires. These issues were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director during an interview on 1/23/25.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents, leading to deficiencies in their care. Resident #12, who has a pacemaker, did not have a comprehensive care plan detailing how the pacemaker should be monitored, and there was no evidence of cardiology follow-up. Additionally, the resident's fall intervention plan, which included non-skid strips next to the bed, was not implemented, as observed by the surveyor and confirmed by staff interviews. Resident #91, who suffers from hemiplegia and contractures, was not provided with the prescribed right-hand splint and arm wedge as per the care plan. Observations over multiple days showed that the resident was not wearing these assistive devices, and there was no documentation of refusal or any indication that the care plan was being followed. Staff interviews revealed a lack of awareness regarding the non-implementation of these devices. Resident #13, diagnosed with quadriplegia and a right-hand contracture, was not wearing the prescribed right-hand roll during several observations. The care plan required the hand roll to be worn daily, but there was no documentation of refusal or adherence to the care plan. Staff interviews indicated that the resident did not like wearing the hand roll, but this was not documented, and the care plan was not followed as ordered by the physician.
Failure to Inspect Bed Entrapment Zones
Penalty
Summary
The facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment for residents' beds, leading to potential safety risks. Specifically, a bed bolster used to fill gaps between the mattress and the footboard was improperly fitted, creating a gap of about six inches. This gap was large enough for a surveyor to insert an entire arm, indicating a significant risk of entrapment. The facility's policy requires that bed frames, mattresses, and bed rails be checked for compatibility and size to prevent entrapment, but these checks were not completed as required. The deficiency was further highlighted by incomplete documentation of bed entrapment measurement tests, with only nine beds on the A Unit being partially checked, despite the facility having a capacity of 126 beds. Interviews with the facility's staff revealed that the previous Maintenance Director did not complete the required yearly bed entrapment rounds, and the current Maintenance Director from another facility was tasked with completing them. The Director of Nursing acknowledged that bed safety checks for entrapment were not done, and the bolster used was incorrect, posing a risk of resident entrapment.
Deficiency in Call System Functionality on A Unit
Penalty
Summary
The facility failed to ensure a functioning call system was available for residents on the A Unit, as observed by the surveyor. The call bell system was broken, and the surveyor noted that the call bell did not sound in the hallway or at the nursing station, and the call bell board did not illuminate to identify which bedroom requested help. Some hallway call lights activated, but they were not visible from the nursing station. Many residents were unaware of the broken system and continued to use the call bell, leading to complaints about late response times. The surveyor observed that several residents did not have hand bells, and for those who did, the bells were often out of reach. Interviews with staff revealed that the call light system began malfunctioning in November 2024 and stopped functioning entirely by mid-December 2024. The Unit Manager was aware of the issue and had instructed staff to distribute hand bells, but this was not consistently done. The Administrator was also aware of the broken system and expected staff to provide hand bells. The Consulting Maintenance Director, unfamiliar with the building's required repairs, confirmed that the maintenance log documented the need for repairs in October and December 2024, but the system had not been repaired.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident who was admitted in January 2025 with diagnoses including chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination, and dysphagia. The resident required assistance with meal setup or clean-up, as indicated in their care plan and functional abilities assessment. However, during a survey observation, it was noted that the resident was left to manage their meal independently, using their teeth to open a creamer and eating pancakes with their hands due to limited use of their fingers. The resident reported that staff had not previously offered assistance with opening lids or cutting food, and they were unsure if such help was available. Interviews with the unit manager revealed that staff were expected to offer meal assistance, including cutting up food for the resident. The unit manager acknowledged that a new meal distribution system was in place, and some staff were still learning about the specific needs of individual residents. The resident confirmed that on one occasion, a staff member did cut up their meal, marking the first time this had occurred since their admission. This lack of consistent assistance led to the resident's inability to dine in a dignified manner, as required by the facility's policy on dignity.
Failure to Follow Physician's Orders for Wound Care and Oxygen Tubing
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. For Resident #175, who was admitted with conditions including chronic kidney disease and an ulcer on the left great toe, the facility did not change a soiled wound dressing for three consecutive days. The physician's order required daily dressing changes, but the dressing observed by the surveyor was dated three days prior, indicating it had not been changed as documented in the Treatment Administration Record (TAR). Interviews with nursing staff revealed a misunderstanding of the dressing change frequency, and documentation errors were noted. For Resident #68, who required continuous oxygen due to chronic obstructive pulmonary disorder (COPD) and other respiratory issues, the facility failed to change the oxygen tubing for approximately three weeks. The physician's order did not specify a schedule for tubing changes, and the Treatment Administration Record lacked documentation of any changes since admission. The surveyor found the tubing undated and disconnected, resulting in the resident not receiving oxygen. Following the surveyor's observation, a new physician's order was entered to establish a schedule for oxygen equipment maintenance. Interviews with the Director of Nursing (DON) confirmed that it was the nursing staff's responsibility to follow physician's orders and facility policies, which were not adhered to in these cases. The DON acknowledged the need for accurate documentation and obtaining necessary physician's orders for routine procedures like oxygen tubing changes. These deficiencies highlight lapses in following established care protocols and documentation practices within the facility.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #175, who required help with meal setup due to medical conditions including chronic kidney disease, heart disease, muscle wasting, atrophy, difficulty walking, lack of coordination, and dysphagia. Upon admission, the resident's care plan indicated a need for staff assistance with meal setup and cleanup. However, observations revealed that staff did not consistently offer the required assistance. On one occasion, a staff member only partially assisted by removing the lid from a juice cup, leaving the resident to struggle with opening other items using their teeth and hands, despite having limited use of their fingers. Interviews with the resident revealed that this lack of assistance had been ongoing since their admission, with staff typically leaving meal trays without offering help. The resident expressed uncertainty about whether they could request such assistance. A unit manager acknowledged that staff were supposed to offer to cut up the resident's meals and attributed the oversight to a new meal distribution system and staff still learning about individual resident needs. This deficiency highlights a failure in the facility's responsibility to ensure residents do not lose the ability to perform activities of daily living without a medical reason.
Failure to Provide Appropriate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who was dependent on renal dialysis and had an arteriovenous fistula, experienced bleeding at the fistula site on multiple occasions. Despite facility policy requiring documentation and communication with the dialysis center, the nursing staff did not document the location of the catheter, the condition of the dressing, or any post-dialysis observations in the resident's medical record. Additionally, there was no communication with the dialysis center regarding the resident's condition post-dialysis, and the practitioner was not notified of the bleeding as required by the physician's orders. The resident's care plan and physician orders specified the need for monitoring and reporting any signs of bleeding or other complications. However, the nursing progress notes and the Dialysis Center Communication Book lacked the necessary documentation and communication. Observations by the surveyor revealed that the resident's fistula was covered with undated and uninitialed dressings, indicating a lack of proper documentation and follow-up by the nursing staff. Interviews with the nursing staff and management confirmed the absence of required communication and documentation, highlighting a failure to adhere to facility policy and physician orders.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. For one resident with hemiplegia and contractures, the Treatment Administration Record (TAR) inaccurately indicated that the resident was wearing a right-hand splint and arm wedge, despite multiple observations by a surveyor showing otherwise. The resident's medical record did not document any refusal to wear these devices, and interviews with the Unit Manager and Director of Nursing confirmed that the documentation should reflect the actual care provided. Another resident with quadriplegia and a right-hand contracture was similarly affected by inaccurate documentation. The TAR stated that the resident was wearing a right-hand roll, but observations showed the resident was not wearing it during several checks. Again, there was no documentation of refusal in the medical record, and facility staff acknowledged that the documentation should have been accurate and reflective of the resident's condition and care. A third resident with an ulcer on the left great toe experienced a failure in wound care documentation. The TAR indicated that dressing changes were performed on specific dates, but observations revealed that the dressing had not been changed since a prior date, as evidenced by the unchanged dressing date. Interviews with nursing staff revealed a misunderstanding of the dressing change orders, and the Director of Nursing confirmed the responsibility of staff to document accurately in the clinical record.
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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