Presentation Rehab And Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 10 Bellamy Street, Boston, Massachusetts 02135
- CMS Provider Number
- 225486
- Inspections on file
- 18
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Presentation Rehab And Skilled Care Center during CMS and state inspections, most recent first.
The facility failed to adhere to physician orders for four residents, including not obtaining weekly and daily weights for residents with severe cognitive impairment, end-stage renal disease, and heart failure. Additionally, a resident with a wound did not receive daily dressing changes as ordered. Staff interviews confirmed lapses in following protocols for weight monitoring and wound care.
The facility failed to ensure safety measures for three residents, leading to deficiencies in accident prevention. A resident with severe cognitive impairment did not have the required bed alarm and floor mats in place. Another resident, also with cognitive impairment, was left unsupervised despite needing 1:1 supervision, and the motion sensor alarm was off. A third resident with dementia and Parkinson's disease lacked the necessary floor mats on both sides of the bed, as ordered by the physician.
The facility failed to properly store and label medications, with inhalers and medications not dated when opened, and orally administered medications not separated from external treatments. Medication carts contained loose pills, sticky substances, and staff medications, contrary to policy. Staff acknowledged these issues, and the DON confirmed expectations for proper storage and cleanliness.
The facility failed to properly store and handle food, with several items in the kitchen refrigerators found undated or past their labeled dates, and cooks not following proper hygiene practices during food preparation. This included not changing gloves between tasks, potentially contaminating food. The facility's policies on food storage and handling were not adhered to, as confirmed by the Food Service Director.
The facility failed to maintain accurate medical records and documentation for several residents, leading to deficiencies in care. A resident's skin assessments did not document a deep tissue injury, another resident was incorrectly diagnosed with Bipolar disorder, and a third resident's bed alarm and floor mats were not properly documented or implemented. Additionally, a resident received a higher oxygen flow rate than ordered without proper documentation or physician notification.
The facility failed to ensure staff wore precaution gowns when required for residents on contact and enhanced barrier precautions. Staff, including CNAs and the ADON, were observed providing care without gowns, despite signage indicating the need for such precautions. Additionally, a nurse did not clean an insulin vial before use, violating infection control protocols. Interviews confirmed the necessity of these precautions, but inconsistencies in their implementation were noted.
A resident with dementia and moderate cognitive impairment, dependent on staff for toileting, was instructed by a private aide to use a diaper instead of being assisted to the bathroom. This occurred despite the facility's policy on dignity, which requires prompt response to toileting requests. The Unit Manager and DON acknowledged the inappropriate response and clarified that private aides should ensure a dignified experience, while facility staff should provide care.
A resident with anxiety was subjected to verbal abuse by the Admissions Director, who engaged in a loud and aggressive conversation about the resident's issues with roommates. The resident felt accused and upset, and the incident was witnessed by a surveyor and confirmed by a Unit Manager. The facility's policy on abuse prevention was violated, as the Admissions Director admitted her conduct was inappropriate.
The facility failed to implement the care plan for two residents, leading to a deficiency related to the non-application of foot protection booties. One resident with traumatic brain injury and hemiplegia, and another with severe cognitive impairment and a deep tissue injury, were observed without the required booties despite physician orders. Staff interviews confirmed the oversight, with some unaware of the non-compliance and others noting that the overnight shift often forgot to apply the booties.
A resident with dysphagia and cognitive impairment was left unsupervised during meals, despite a physician's order requiring feeding assistance. Observations showed the resident attempting to eat and drink alone, with staff unaware of the need for supervision. Interviews confirmed the requirement for staff presence during meals to prevent aspiration, indicating a lapse in following the care plan.
Two residents in an LTC facility were found to lack adequate activity programming, leading to feelings of boredom and isolation. One resident with a traumatic brain injury and another with cerebral palsy were observed confined to their rooms without activity supplies. Despite care plans indicating participation in activities, attendance logs showed minimal engagement. The Activities Director cited staffing constraints as a challenge in following the activity calendar.
A resident with moderate cognitive impairment and hearing loss was not assisted by the facility in maintaining hearing abilities. Despite the facility's policy, staff failed to arrange an audiology appointment to replace a lost hearing aid, and no alternative hearing devices were provided. The resident expressed frustration over the inability to hear, and interviews revealed a lack of communication among staff regarding the resident's needs.
The facility failed to follow physician's orders for air mattress settings for two residents with pressure ulcers. One resident's mattress was set incorrectly multiple times, despite a sticker indicating the correct setting. Another resident's mattress was also set incorrectly, contrary to the sticker's instructions. A nurse confirmed the settings should be based on physician's orders or the sticker.
Two residents with contractures were not provided with the necessary splint interventions as prescribed, leading to a deficiency in care. One resident with hemiplegia was observed multiple times without a left-hand splint, and staff were unable to locate it. Another resident with cerebral palsy was found without bilateral hand splints, which were observed on the ground. Despite physician orders and staff education, the facility failed to ensure the residents wore their splints as required.
A resident with COPD and emphysema was observed receiving oxygen at 5 lpm, contrary to the physician's order of 4 lpm. The resident reported difficulty breathing at lower rates and frequently asked staff to check the oxygen settings. There was no documentation of the need for increased oxygen, and the physician was not informed of the resident's request for a higher flow rate until later, indicating a failure in communication and documentation by the facility staff.
A resident was served pork products despite having communicated a no pork preference due to religious reasons. The facility lacked a regular dietician, and the Food Service Director was unaware of the preference until after the resident was served bacon and a ham sandwich.
Failure to Adhere to Physician Orders for Weight Monitoring and Wound Care
Penalty
Summary
The facility failed to meet professional standards of quality for four residents by not adhering to physician orders regarding weight monitoring and wound care. For one resident, the facility did not obtain weekly weights as ordered by the physician, despite the resident having severe cognitive impairment and a history of severe protein-calorie malnutrition. The weight records showed significant gaps in the weekly weight documentation, and there was no indication of refusal or behaviors that would prevent obtaining the weights. Another resident, who was dependent on dialysis due to end-stage renal disease, did not have pre and post-dialysis weights documented as per physician orders. The facility's policy required coordination with the dialysis center and documentation of weights in the Medication Administration Record (MAR), but several dates showed missing or incomplete weight records. Interviews with staff confirmed that the responsibility for documenting these weights was not fulfilled. Additionally, a resident with acute systolic congestive heart failure did not have daily weights recorded as ordered, which is crucial for monitoring fluid overload. The Treatment Administration Record lacked daily weight entries, and interviews with staff confirmed that the weights should have been obtained. Lastly, a resident with a wound on the right knee did not have daily dressing changes as ordered, with an observation showing a dressing dated two days prior. The facility's protocol required daily dressing changes, and staff interviews revealed that the responsibility for wound care was not adequately managed when the wound nurse was unavailable.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to maintain a safe environment for three residents, leading to deficiencies in accident prevention and supervision. Resident #82, who had severe cognitive impairment and was at high risk for falls, did not have the physician-ordered bed alarm and floor mats properly implemented. Observations revealed that the bed alarm was disconnected, and only one floor mat was in place, contrary to the physician's orders for bilateral floor mats. Interviews with staff confirmed the lack of adherence to the prescribed safety measures. Resident #23, also with severe cognitive impairment and a high fall risk, was not provided with the required 1:1 supervision as per the plan of care. The resident was observed alone in the room without staff presence, and the motion sensor alarm intended to alert staff was found to be switched off. Staff interviews indicated a misunderstanding of supervision responsibilities, with reliance on the non-functioning alarm instead of direct supervision. Resident #90, diagnosed with dementia and Parkinson's disease, was similarly at high risk for falls and required floor mats on both sides of the bed. However, observations showed that only one floor mat was in place, with the other folded in the corner of the room. Staff interviews confirmed the oversight, acknowledging the failure to implement the physician's order for bilateral floor mats, which was crucial for the resident's safety.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. Inhalers and medications with shortened expiration dates were not dated once opened, which is against the facility's policy. Additionally, orally administered medications were not kept separate from externally used medications and treatments, such as suppositories and ointments. The medication storage areas were found to be cluttered, with loose pills and sticky substances present, and some medications were not stored at the required temperatures. Furthermore, medications belonging to staff members were improperly stored in the medication cart, which should only contain medications for residents. During the inspection, several specific instances of non-compliance were noted. Opened inhalers and bottles of prostat were found undated, and acidophilus tablets were not refrigerated as required. Loose pills were found in the medication cart drawers, and a sticky brown substance was observed on bottles and the bottom of the drawers. A plastic bag containing medications belonging to a nurse was also found in the cart. Interviews with nursing staff and the Director of Nursing confirmed these deficiencies, with staff acknowledging the improper storage and lack of a cleaning schedule for the medication carts.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, as observed during a survey. In the kitchen refrigerators, several food items were found either undated or past their labeled dates, including cut melon, ground turkey, and various containers of food such as beans, chicken broth, and cottage cheese. Some items, like a moldy cut lemon and roasted garlic dated over a month prior, were improperly stored, increasing the risk of foodborne illness. The facility's policy requires refrigerated foods to be labeled, dated, and used within an appropriate time frame, which was not followed. Additionally, during breakfast preparation, cooks were observed not following proper hygiene and sanitary practices. One cook, while wearing gloves, handled bacon and its packaging, touched the oven, and continued handling food without changing gloves, potentially contaminating the food. Another cook was seen using the same gloves to handle bread, a knife, and toaster dials, again risking contamination. The facility's policy prohibits bare hand contact with food and mandates changing gloves between tasks, which was not adhered to. The Food Service Director confirmed that staff should wash hands and change gloves when moving between tasks and that items in the fridge should be labeled with the date made and used within three days.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in care. For Resident #3, the facility did not complete accurate skin assessments, as the weekly assessments failed to document a deep tissue injury on the resident's left great toe, despite wound notes indicating its presence. Interviews with the Wound Nurse and Unit Manager confirmed that all skin concerns should be documented in weekly assessments, but this was not done for Resident #3. Resident #106's medical records were inaccurate due to an erroneous diagnosis of Bipolar disorder, which was not supported by the hospital discharge paperwork. The error was acknowledged by the Regional Nurse, indicating a lapse in verifying the accuracy of medical diagnoses upon admission. This oversight led to the administration of medication for a condition that was not diagnosed. For Resident #82, the facility failed to accurately document the functioning of a bed alarm and the presence of floor mats as ordered. Observations revealed that the bed alarm was disconnected, and a floor mat was missing from one side of the bed, contrary to the physician's orders. Similarly, Resident #88's oxygen flow rate was documented inaccurately, as the resident was observed receiving a higher flow rate than ordered, without proper documentation or physician notification. Interviews with nursing staff confirmed that these discrepancies were not communicated or documented as required.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to transmission-based precautions, specifically in the use of precaution gowns when required. Observations revealed that staff, including CNAs and the ADON, did not wear precaution gowns while providing care to residents on contact and enhanced barrier precautions. This included activities such as washing up residents, shaving, and handling soiled materials. Despite signage indicating the need for gowns and gloves, staff were observed entering rooms and performing care without the appropriate protective equipment. Additionally, the facility did not ensure proper infection control practices were followed when handling medical supplies. A nurse was observed drawing up insulin from a vial without cleaning the vial top with alcohol, which is a standard infection control practice. This oversight was acknowledged by the nurse during an interview, indicating a lapse in following established protocols for medication administration. Interviews with various staff members, including the Unit Manager, DON, and Regional Nurse, confirmed the necessity of wearing precaution gowns and gloves when providing direct care to residents on enhanced barrier precautions. However, there was inconsistency in the understanding and implementation of these precautions, particularly concerning handling trash and other objects in rooms of residents on contact precautions. The DON expressed concern specifically about the lack of gown use when handling drainage from a cholecystostomy bag, highlighting a critical area of non-compliance with infection control standards.
Failure to Maintain Resident Dignity in Toileting Assistance
Penalty
Summary
The facility failed to provide a dignified existence for a resident with moderate cognitive impairment, who was dependent on staff for toileting tasks. The resident, diagnosed with dementia, was admitted to the facility in August 2016. On two separate occasions, the resident expressed the need to use the bathroom to a private aide hired by the family. Instead of facilitating the resident's request, the aide instructed the resident to use the diaper, which is contrary to the facility's policy on dignity that emphasizes treating residents with respect and promptly responding to toileting requests. The Unit Manager and the Director of Nursing (DON) acknowledged the inappropriate response of the private aide, noting that the aide should have offered a bedpan or sought assistance from facility staff. The DON clarified that private aides are meant for companionship and socialization, while the facility staff is responsible for providing care. Despite this, the expectation remains that private aides should also ensure a dignified experience for residents. The failure to intervene by the facility staff when the aide instructed the resident to use the diaper further contributed to the deficiency in maintaining the resident's dignity.
Verbal Abuse Incident Involving Admissions Director
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as observed during an interaction between the Admissions Director and a resident. The incident occurred when the Admissions Director and the resident were engaged in a loud conversation regarding the resident's difficulties with roommates. The Admissions Director's voice became aggressive, and she was overheard yelling at the resident, warning them about their behavior. This interaction was witnessed by a surveyor and was later confirmed by Unit Manager #2, who intervened to de-escalate the situation. The resident expressed feeling upset and accused of causing issues with previous roommates, which made them feel bad. The resident involved had been admitted to the facility with a diagnosis of anxiety and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The facility's policy on abuse prevention defines verbal abuse as the use of language that includes disparaging and derogatory terms, which was violated in this instance. The Admissions Director acknowledged her frustration and admitted that her warning to the resident was inappropriate. The facility's Administrator confirmed that staff are expected to communicate with residents kindly and professionally, and the Admissions Director's conduct did not align with these expectations.
Failure to Implement Care Plan for Foot Protection Booties
Penalty
Summary
The facility failed to implement the care plan for two residents, resulting in a deficiency related to the non-application of foot protection booties. Resident #1, admitted with diagnoses including traumatic brain injury and hemiplegia, was observed multiple times with feet directly on the bed, despite physician orders and a care plan requiring bilateral heel booties while in bed. The medical record did not indicate any refusal of the booties by the resident. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the resident should have been wearing the booties, but they were unaware of the non-compliance. Similarly, Resident #3, with severe cognitive impairment and a deep tissue injury, was also observed without the required foot booties on several occasions. The resident's care plan and physician orders specified the use of bilateral heel booties while in bed, yet observations showed the booties were not applied. Staff interviews revealed that the overnight shift often forgot to apply the booties, and there was a misunderstanding about when the booties should be worn. The Director of Nursing emphasized that all orders should be followed unless a resident refuses the intervention, which was not documented in this case.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision and assistance with eating for a resident who was unable to perform activities of daily living independently. The resident, admitted in July 2023, had diagnoses including dysphagia and left-sided hemiparesis following a stroke, and was assessed to have moderate cognitive impairment. The resident's care plan included a physician's order stating that the resident must be fed all meals, indicating the need for staff supervision during meals. However, observations on multiple occasions revealed the resident attempting to eat and drink without assistance, with no staff present in the room. Interviews with staff members, including CNAs and nursing leadership, confirmed that the resident required supervision during meals to prevent risks such as aspiration. Despite this, the resident was left alone with meal trays, contrary to the physician's order and facility policy. Staff members, including the primary aide and the DON, acknowledged the need for supervision and feeding assistance, highlighting a failure in communication and adherence to the resident's care plan and safety protocols.
Deficiency in Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident #1, who has a traumatic brain injury and hemiplegia, was observed to be confined to their room throughout the survey period, with no activity supplies available. The resident's care plan indicated enjoyment of various activities, but there was no evidence of participation in group activities or sensory programs. The Activities Director noted that Resident #1 often missed group activities due to the need for extensive care and not being out of bed in time. Similarly, Resident #69, diagnosed with cerebral palsy, was also observed to be confined to their room, with no activity supplies present. Despite having a cognitive status that allows for participation, the resident expressed a desire to engage in social activities but was not observed participating in any group activities. The resident's care plan included goals for attending group activities, but attendance logs showed no participation beyond in-room activities and an ice cream social. The Activities Director, who is the sole staff member in the department, acknowledged the difficulty in adhering to the activity calendar due to staffing constraints. Both residents were not provided with adequate opportunities for social interaction or engagement in activities that could enhance their well-being, as required by the facility's policy. This lack of activity programming contributed to the residents' feelings of boredom and isolation, as reported by the residents themselves and observed by the surveyors.
Failure to Assist Resident with Hearing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for a resident who was admitted with diagnoses including chronic obstructive pulmonary disease and emphysema. The resident had moderate cognitive impairment and required hearing aids for adequate hearing. Despite the facility's policy to assist hearing-impaired residents, the resident's care plan did not reflect the use or presence of hearing aids, and staff did not arrange for an audiology appointment to replace a lost hearing aid. The resident expressed frustration over the inability to hear staff, and no alternative hearing amplification devices or interventions were provided. Interviews with staff revealed that the Assistant Director of Nursing and Unit Manager were aware of the need for an audiology appointment but had not contacted audiology services. The Quality Assurance Nurse, responsible for arranging such services, was unaware of the resident's needs and had not scheduled an appointment. The Director of Nursing was also unaware of the missing or broken hearing aids. This lack of communication and follow-through resulted in the resident being unable to hear effectively, impacting their ability to communicate with staff and others.
Failure to Follow Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to physician's orders regarding air mattress settings for pressure ulcer prevention for two residents. Resident #91, who was admitted with pressure ulcers on both heels and is severely cognitively impaired, had a physician's order for a low air loss mattress with specific settings to be checked every shift. However, observations revealed that the air mattress settings were consistently incorrect, with the dial set to 200, 400, and over 400, despite a sticker indicating it should be set to 160. Nurse #7 confirmed that the settings should be determined by the physician's orders or the sticker on the dial. Similarly, Resident #102, admitted with a pressure ulcer in the sacral region and moderately impaired, had a physician's order to ensure the air mattress was set correctly every shift. Observations showed the mattress was set to 160, contrary to the sticker indicating it should be set to 100. Nurse #7 reiterated the process of checking the physician's orders or the sticker for the correct settings. These discrepancies indicate a failure to follow prescribed care protocols for pressure ulcer prevention.
Failure to Implement Splint Use for Residents with Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent increased contractures for two residents, leading to a deficiency in care. Resident #30, who was admitted with hemiplegia and hemiparesis following a stroke, was observed multiple times without the prescribed left-hand splint, which was intended to be worn for up to 6 hours daily. Despite having a care plan and physician orders for the use of a splint, the resident was not wearing it, and staff were unable to locate the splint in the resident's room. Interviews with staff revealed a lack of follow-through in ensuring the resident wore the splint as ordered. Similarly, Resident #69, diagnosed with cerebral palsy, was observed without the prescribed bilateral hand splints on several occasions. The resident, who is cognitively intact, reported that they often do not wear the splints and cannot put them on independently. The splints were found on the ground, and despite physician orders and staff education on the use of the splints, they were not being applied as required. Interviews with staff confirmed that the splints should be worn daily, but there was a failure to ensure this was happening. The deficiency in care for both residents highlights a breakdown in the facility's restorative program and the transition of care from therapy to nursing. Despite having orders and care plans in place, the facility did not ensure the residents received the necessary interventions to prevent further contractures, as evidenced by the lack of splint use and the inability of staff to locate or apply the splints as prescribed.
Failure to Follow Oxygen Flow Rate Orders
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD) and emphysema. The resident was observed multiple times with an oxygen flow rate set at 5 liters per minute (lpm), despite the physician's order specifying 4 lpm. The resident expressed difficulty breathing at lower rates and frequently requested staff to check the oxygen settings. However, there was no documentation in the medical record indicating a need for increased oxygen or that a higher flow rate was administered. Interviews with the Assistant Director of Nursing (ADON) and Unit Manager revealed that nursing staff should check the oxygen flow rate at least once per shift and communicate any changes or refusals to the physician, which was not done in this case. The Director of Nursing (DON) confirmed that oxygen should be administered as ordered and that any adjustments should be documented and communicated to the physician. The physician was unaware of the resident's request for increased oxygen until contacted by the ADON, highlighting a lapse in communication and documentation.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preference by serving pork products despite the resident's explicit request to avoid them due to religious reasons. The resident, who was cognitively intact, communicated their no pork preference to the Food Service Director, and the resident's daughter also highlighted this preference on the facility's weekly menu. However, the resident was served bacon for breakfast and a ham sandwich for dinner, contrary to their dietary restrictions. The deficiency occurred partly because the facility did not have a regular dietician on staff to assess and communicate the resident's food preferences upon admission. Instead, the responsibility fell to the Food Service Director, who was unaware of the resident's no pork preference until after the resident had already been served pork products. The Unit Manager indicated that dietary preferences were typically reviewed based on discharge paperwork, which did not include the resident's specific dietary restrictions.
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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