Quabbin Valley Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Athol, Massachusetts.
- Location
- 821 Daniel Shays Highway, Athol, Massachusetts 01331
- CMS Provider Number
- 225296
- Inspections on file
- 25
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Quabbin Valley Healthcare during CMS and state inspections, most recent first.
A resident admitted with a Stage II coccyx pressure injury and diagnoses including schizoaffective disorder and type 2 DM did not have required Enhanced Barrier Precautions (EBP) implemented per facility policy. The policy required EBP, including posted signage, a precaution cart with gowns and gloves, and use of gown and gloves during high-contact care such as wound care for any resident with a wound. During an observed dressing change, there was no EBP signage or cart at the room, and an RN wore only a mask and gloves, removed the old dressing, cleansed the open coccyx wound, applied Santyl, and redressed the wound without a gown. The RN stated she believed a gown was unnecessary because the resident did not have MRSA and there was no EBP sign, while the IP confirmed the resident should have been on EBP and a gown should have been used during wound care.
A resident with severe cognitive impairment and total dependence on staff for bed mobility was repositioned by a single CNA, despite a care plan and CNA Care Card specifying the need for two-person assistance. The CNA did not review the Care Card before providing care, leading to the resident sliding off the bed and falling. Staff interviews confirmed the care plan requirements were not followed.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility and positioning, was cared for by only one CNA who did not consult the Care Card outlining this requirement. During care, the resident slid off the bed and fell to the floor, as the CNA was unable to prevent the fall alone. The incident occurred despite facility policies and accessible documentation specifying the need for two staff members for such care.
Two residents who required wheelchairs were unable to access the bathrooms in their rooms due to doorways that were narrower than their wheelchairs. One resident had to maneuver awkwardly to use the bathroom and often waited for a shared accessible bathroom, while another sustained a minor injury and was unable to use the toilet or sink, instead using a container to empty a urinary catheter. Staff confirmed that most wheelchairs could not fit through the bathroom doors on certain units.
Surveyors found that multiple rooms housing two residents each did not meet the required 80 square feet per resident, with at least one room measuring only 75 square feet per resident. The Administrator confirmed the deficiency and noted the rooms were in an older section of the facility.
A resident with a history of wandering and cognitive impairment fell and sustained a hip fracture due to inadequate supervision in a secure unit. The resident was ambulating in the hallway without staff supervision, as the supervising nurse was in a location without visibility of the hallway, and the CNAs were attending to another resident. The facility's policy required supervision during ambulation, which was not provided, resulting in the resident's fall and injury.
A resident with severe cognitive impairment was improperly restrained by a CNA using a sheet tied around their waist to prevent disrobing while the CNA attended to other residents. The restraint was discovered the next morning when another CNA attempted to transfer the resident. The facility's policy prohibits restraints for convenience, and the incident was confirmed as improper use of a physical restraint.
The facility failed to obtain physician's orders before administering COVID-19 rapid tests to three residents. Nursing progress notes indicated that the tests were conducted without documented orders in the residents' medical records. The Infection Preventionist confirmed the absence of orders and acknowledged that they should have been documented upon admission.
A resident with a history of Anxiety Disorder, COPD, and CHF was transferred to the hospital without the necessary documentation, including medical history and transfer reasons, as required by the facility's policy. The transfer form was initiated but not completed, and essential documents like Advanced Directives and provider information were not sent, putting the resident at risk for complications.
The facility failed to provide necessary respiratory care for two residents. One resident with COPD had an oxygen flow rate set higher than the physician's order, with frost on the equipment indicating improper maintenance. Another resident's nebulizer tubing was not changed weekly as ordered, and the treatment record inaccurately reflected changes. These issues demonstrate lapses in adhering to physician orders and maintaining equipment.
A facility failed to maintain accurate medical records for a resident with COPD, as the nebulizer tubing was not changed weekly as ordered. Despite documentation indicating changes on specific dates, the tubing was observed to be unchanged since a prior date. This discrepancy was confirmed by the Unit Manager, revealing a failure to adhere to professional standards.
A facility failed to follow infection control protocols for two residents. One resident, showing COVID-19 symptoms, was not tested immediately despite an outbreak, delaying testing by four days. Another resident's urinary drainage bag was improperly stored uncovered on a bathroom handrail, contrary to policy requiring it to be in a plastic bag. These deficiencies were confirmed by staff interviews and observations.
The facility failed to administer the Pneumococcal Vaccine to two residents, increasing their risk for infections. One resident with COPD was not offered the vaccine when eligible, despite previous vaccinations. Another resident with emphysema and chronic kidney disease was not given the PCV20 vaccine, despite being eligible and having consent from the Health Care Proxy. The Infection Preventionist and IP Nurse confirmed these oversights, leaving the residents at risk due to their high-risk environment and health conditions.
The facility failed to ensure that 15 resident rooms met the required 80 square feet per resident, with rooms measuring only 75 square feet. Despite this, the room sizes did not compromise resident health and safety. The Administrator requested a waiver from the Department of Public Health, citing cost prohibitions and potential loss of beds, but had not received a response.
The facility failed to protect two residents from abuse by staff members. One resident was forcefully transferred and pushed down onto their bed by a CNA, resulting in new bruises and fear. Another resident had their call light removed by a CNA, leaving them unable to request assistance. Both incidents were substantiated, and the CNAs involved were terminated.
A facility failed to ensure staff followed their Abuse Policy when a nurse aide witnessed a CNA place a resident's call light out of reach and did not report the incident until the end of their shift. The resident, who was dependent on staff for personal care and cognitively intact, confirmed the incident, which made them feel upset.
A facility failed to report an abuse allegation within the required two-hour timeframe. A resident's call light was deliberately removed by a CNA, and the incident was reported to the DON but not to the DPH until the following day, exceeding the mandated reporting window by more than 16 hours.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident admitted with a Stage II pressure injury on the coccyx. The facility’s policy, effective 01/2023, required EBP for any resident with a wound, including chronic and surgical wounds, and specified that gowns and gloves must be worn for high-contact care activities such as wound care. The policy also required EBP signage to be posted outside the resident’s room and a precaution cart with gowns and gloves to be available, with precautions to remain in place for the duration of the resident’s stay or until the wound healed. Resident #2, admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, had a coccyx wound requiring daily dressing changes per physician order. On observation during a wound care dressing change, there was no EBP signage or precaution cart with gowns and gloves at the resident’s door, despite the resident meeting criteria for EBP under facility policy. The nurse performing the dressing change donned only a mask and gloves, did not wear a gown, and proceeded to remove the old dressing, cleanse the open, shallow coccyx wound with scant drainage and yellow tissue, apply Santyl, and place a new dressing. In interview, the nurse stated she did not think a gown was needed because the resident did not have MRSA and there was no EBP sign posted. The Infection Preventionist later confirmed that the resident should have been placed on EBP upon admission due to the presence of a wound and that the nurse should have worn a gown during wound care per facility policy.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility and positioning, was repositioned in bed by a single CNA without the required assistance of a second staff member. The resident's care plan and CNA Care Card both clearly indicated the need for two staff members to assist with bed mobility and positioning. Despite this, the CNA proceeded alone, resulting in the resident sliding off the bed and falling to the floor. The CNA involved stated that she was not familiar with the resident's care needs and did not check the Care Card prior to providing care. She had previously cared for the resident on a different unit but was unaware of the two-person assist requirement. Although another CNA was present in the room, she was attending to a different resident and did not assist or witness the fall. The facility's policy required all staff to be familiar with and follow the care plan, and the Care Cards were accessible at the nursing station for staff reference. Interviews with facility staff, including the unit manager and DON, confirmed that the resident was completely dependent on staff and that the Care Card accurately reflected the need for two-person assistance. The incident was witnessed and reported, and the CNA acknowledged not reviewing the Care Card before providing care, which directly led to the failure to implement the care plan as required.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on two staff members for bed mobility and positioning, was provided care by only one CNA. The resident's care plan and CNA Care Card both indicated the need for assistance from two staff members for bed mobility and positioning due to significant physical and cognitive impairments, including unspecified dementia with agitation and adjustment disorder. Despite these documented requirements, the CNA did not consult the Care Card prior to providing care and was unaware of the resident's need for two-person assistance. During morning care, the CNA attempted to reposition the resident alone. While the CNA was preparing to provide incontinent care, the resident began to slide off the bed. The CNA tried to reposition the resident but was unable to prevent the resident from sliding off the bed and falling to the floor. Another CNA was present in the room but was attending to a different resident and did not assist with the care of the resident in question. The incident was witnessed, and the resident was assessed to have no injuries immediately following the fall. Interviews with staff confirmed that the CNA responsible for the resident's care did not check the Care Card and was not familiar with the resident's specific care needs. The facility's policy required all caregivers to be aware of and follow care plan interventions, and the Care Cards were accessible at the nursing station. The failure to consult the Care Card and provide the required level of assistance directly led to the resident's fall from bed during care.
Inaccessible Bathroom Facilities for Wheelchair Users
Penalty
Summary
The facility failed to ensure that residents who required the use of a wheelchair for mobility had access to a bathroom in or near their rooms that could be quickly and safely accessed. For two residents, the bathroom doorways in their rooms were narrower than the width of their wheelchairs, preventing direct entry. One resident, who was cognitively intact and required moderate assistance for transfers, had to position their wheelchair at an angle in the doorway and pull themselves up using a grab bar inside the bathroom, while staff stood outside the bathroom and out of reach. This resident reported difficulty accessing the bathroom and often had to wait to use a more accessible bathroom in the hallway, which was frequently occupied. Another resident, who had moderate cognitive impairment, neuropathic bladder, a colostomy, and chronic kidney disease, was unable to fit their wheelchair through the bathroom door and sustained a minor injury when attempting to enter. This resident was provided with a container to empty their urinary catheter bag because they could not access the toilet or sink in the bathroom. Staff interviews confirmed that the bathroom doors on certain units were too small for most wheelchairs, and the facility attempted to place only ambulatory residents in those rooms due to the limited doorway size.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 14 resident rooms, each housing two residents, met the required minimum of 80 square feet per resident in multi-bed rooms. On observation, one such room was measured at only 75 square feet per resident. This deficiency was identified through direct observation, interviews, and record review by surveyors. The affected rooms were located in a section of the facility built in 1958, and the Administrator acknowledged that these rooms did not meet the current size requirements. Despite the deficiency, surveyors noted that the room sizes did not compromise the health and safety of the residents at the time of the survey.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of wandering and cognitive impairment, resulting in a fall and injury. The resident, who resided on a secure unit, was known to wander during the evening shift and required staff supervision while ambulating. On the evening of the incident, the resident was ambulating in the hallway without supervision and fell, sustaining a hip fracture that required surgical intervention. The facility's policy required staff to supervise residents during ambulation, as indicated in the resident's care plan. However, on the night of the incident, the supervising nurse was in the Day Room, which did not allow visibility of the hallway where the resident was ambulating. The two CNAs on duty were attending to another resident, leaving the hallway unsupervised. This lack of supervision was a contributing factor to the resident's fall. Interviews with staff revealed that the resident was known to be up frequently and had a history of falls, including one in the previous month. Despite this, the staff did not maintain the required level of supervision. The unit manager and DON acknowledged that the resident should have been supervised during ambulation, but the staff failed to do so, leading to the resident's fall and subsequent injury.
Improper Use of Physical Restraint on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for the convenience of staff rather than for medical treatment. The incident involved a resident with a neurocognitive disorder with Lewy body, dementia with behavioral disturbance, and delusional disorder, who was severely cognitively impaired. The resident frequently demonstrated behaviors such as disrobing and unsafe rising from a chair, particularly during the evening and overnight shifts. On the night of the incident, a Certified Nurse Aide (CNA) placed a sheet across the resident's waist and tied it behind the reclining chair to prevent the resident from disrobing while the CNA attended to other residents. The CNA did not seek assistance from other staff members, as they were busy, and forgot to untie the sheet before leaving at the end of the shift. The restraint was discovered the following morning when another CNA attempted to transfer the resident and found them unable to stand due to being tied to the chair. The facility's policy on physical restraints clearly states that residents have the right to be free from restraints used for discipline or convenience. The Director of Nurses confirmed that the use of the sheet as a restraint was inappropriate and not in line with the facility's restraint-free policy. The incident was substantiated as improper use of a physical restraint, leading to the termination of the CNA involved.
Failure to Obtain Physician's Orders for COVID-19 Testing
Penalty
Summary
The facility failed to obtain physician's orders prior to administering COVID-19 rapid tests for three residents. Specifically, the facility administered COVID-19 rapid tests to Residents #25, #103, and #112 without having documented physician's orders for these tests in their medical records. This oversight was identified through a review of nursing progress notes and physician's orders for each resident, which showed no documentation of orders for the COVID-19 rapid tests. During an interview, the Infection Preventionist confirmed that all residents should have a physician's order in place for COVID-19 rapid testing. Upon reviewing the medical records with the surveyor, the Infection Preventionist acknowledged that the orders were missing for the three residents in question. The Infection Preventionist noted that these orders should have been documented in the residents' medical records at the time of their admission to the facility.
Failure to Complete Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, Resident #16, who had a medical history including Anxiety Disorder, COPD, and CHF, was transferred to the hospital without a form that included important information about the resident's medical history and the reason for the transfer. This lack of documentation put the resident at risk for complications and adverse events upon transfer to the hospital. The facility's policy on transfer and discharge procedures was not followed, as evidenced by the absence of discharge paperwork that should have included the resident's Advanced Directives, specific instructions or precautions for ongoing care, and provider information. During an interview, Unit Manager #2 confirmed that the necessary documentation, such as a transfer form, change in condition, and a Nurse's note, was expected to be completed but was not. The transfer form for Resident #16 was initiated but not completed, and the appropriate documentation was not sent with the resident to the hospital as required.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to deficiencies in their care. Resident #12, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease (COPD), was observed with a nasal cannula attached to a portable oxygen tank that had a buildup of frost. The oxygen flow rate was set at 6 liters per minute (LPM), exceeding the physician's order of 0-4 LPM. The frost on the tank and tubing indicated improper maintenance, and the nurse confirmed that the equipment should not have frost and the flow rate was set too high. Resident #54, also diagnosed with COPD, had a nebulizer device with tubing dated 5/27/24, which was not stored in a plastic bag as required. The physician's orders specified that the nebulizer tubing should be changed weekly on Sundays. However, the treatment administration record inaccurately indicated that the tubing had been changed on 6/2/24 and 6/9/24, while the actual tubing had not been changed since 5/27/24. The unit manager confirmed the discrepancy and acknowledged that the tubing was not changed or stored properly. These deficiencies highlight the facility's failure to adhere to physician orders and maintain respiratory equipment according to professional standards. The incorrect oxygen flow rate and improper maintenance of equipment for Resident #12, along with the failure to change and store nebulizer tubing for Resident #54, demonstrate lapses in the facility's respiratory care practices.
Inaccurate Medical Record Keeping for Nebulizer Tubing Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted in January 2023 and had a physician's order to change all oxygen and nebulizer tubing weekly on Sundays, starting from February 2023. However, during an observation on June 11, 2024, the surveyor noted that the nebulizer tubing in the resident's room was dated May 27, 2024, indicating it had not been changed as per the weekly schedule. The Treatment Administration Record (TAR) inaccurately documented that the nebulizer tubing was changed on June 2 and June 9, 2024. Upon review, the Unit Manager confirmed that the tubing had not been changed since May 27, 2024, despite the TAR indicating otherwise. This discrepancy between the actual condition of the equipment and the documentation highlights a failure to adhere to the facility's policy and professional standards for maintaining accurate medical records.
Infection Control Deficiencies in COVID-19 Protocol and Urinary Catheter Storage
Penalty
Summary
The facility failed to implement COVID-19 protocols for a resident who was on Transmission Based Precautions. The resident began showing symptoms indicative of COVID-19, such as a productive cough, decreased appetite, nausea, and vomiting, on June 3, 2024. Despite the facility's policy requiring immediate testing of symptomatic individuals during an outbreak, the resident was not tested until June 7, 2024, after personally requesting a test. This delay occurred even though the COVID-19 outbreak on the unit was identified on June 1, 2024, and the resident's symptoms were documented in nursing progress notes. Another deficiency was identified concerning the storage of a urinary drainage bag for a resident with an indwelling urinary catheter. The facility's policy required that drainage bags be stored in a basin, covered with a plastic bag, and placed in the lower level of the nightstand when not in use. However, observations on June 11 and June 12, 2024, revealed that the urinary drainage bag was hanging uncovered on a bathroom handrail next to the toilet, with the connection tip touching the bathroom wall. This improper storage was confirmed by interviews with CNAs and the Unit Manager, who acknowledged that the bag should have been stored in a plastic bag to prevent contamination. The Infection Preventionist and other staff members confirmed that the facility's policies were not followed in both cases. The failure to adhere to the COVID-19 testing protocol and the improper storage of the urinary drainage bag were identified as deficiencies during the survey. These actions and inactions placed the residents at risk for infection and demonstrated a lack of compliance with established infection control measures.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure the administration of the Pneumococcal Vaccine to two residents, increasing their risk for facility-acquired Pneumococcal infections. Resident #16, who was admitted in August 2018 with COPD, had received previous Pneumococcal vaccinations but was not offered the next appropriate dose when eligible in September 2023. The Infection Preventionist (IP) confirmed that the resident's record was reviewed, and the resident was deemed eligible for the vaccine, but it was not administered as required. Resident #23, admitted in September 2021 with emphysema and chronic kidney disease, was also not administered the PCV20 vaccine despite being eligible since November 2022. The resident's medical record indicated severe cognitive impairment, and the Health Care Proxy had consented to vaccinations per CDC guidelines. The IP Nurse acknowledged that the resident was not brought current with vaccinations, as directed by the physician, leaving the resident at risk for infections due to their high-risk environment, age, and comorbid conditions.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that 15 resident bedrooms met the required square footage of 80 square feet per resident in multi-bed rooms. Specifically, Rooms 101 - 105, 107, 118 - 122, 124 - 126, and 128 were found to measure only 75 square feet per resident. This deficiency was identified through observations made by the surveyor during the survey period. Despite the size discrepancy, it was noted that the room sizes did not compromise the health and safety of the residents residing in these rooms. The Administrator had previously sent a letter to the Department of Public Health on 5/30/24 requesting a waiver for the affected rooms, citing that the rooms were part of the facility's 1958 construction and that enlarging them would be cost prohibitive and could result in the loss of available resident beds. The Administrator had not yet received a response from the Department of Public Health regarding the waiver request.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from abuse by staff members. In the first incident, a Certified Nurse Aide (CNA) was witnessed by a visitor and a nurse forcefully transferring a severely cognitively impaired resident to their bed. The CNA was seen pushing the resident down onto the bed when they tried to get up, causing the resident to become visibly upset and fearful. A subsequent skin assessment revealed new bruises and reddened areas on the resident that were not present before the incident. The facility's internal investigation substantiated the physical abuse allegation, leading to the termination of the CNA involved. In the second incident, another CNA was reported by a nurse aide in training for removing the call light from a cognitively intact resident's reach and telling the resident they were in a time-out for using the call light too much. This left the resident without a means to request assistance. The resident confirmed that the CNA had taken their call light away on multiple occasions, making them feel upset and helpless. The facility's internal investigation substantiated the abuse allegation, and the CNA was terminated. Both incidents highlight the facility's failure to maintain an environment free from abuse, as required by their policy. The residents involved had specific medical conditions that made them particularly vulnerable, and the actions of the CNAs directly contradicted the facility's commitment to ensuring the safety and well-being of its residents.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of abuse allegations. On 04/03/24, during morning care, a nurse aide in training witnessed a CNA place a resident's call light out of reach and tell the resident they were in a time-out. The nurse aide did not report this incident to the Director of Nurses (DON) until the end of their shift, approximately eight hours later. The facility's policy mandates that any knowledge of abuse must be reported to the administration immediately, which was not adhered to in this case. The resident involved was admitted to the facility in May 2023 and had diagnoses including cerebral infarction and adjustment disorder with depressed mood. The resident was dependent on staff for all aspects of personal care and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The resident confirmed that the CNA took their call light away, stating it made them feel upset. The DON confirmed that the nurse aide should have reported the incident immediately rather than waiting until the end of the shift.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as mandated by Federal Regulations and Facility Policy. On 04/03/24, the Director of Nurses (DON) became aware of an incident where a Certified Nurse Aide (CNA) deliberately removed a resident's call light, stating the resident was in a 'time-out.' This incident was reported to the DON at approximately 4:30 P.M., but the facility did not report the incident to the Department of Public Health (DPH) until the following day at 8:16 A.M., exceeding the mandated reporting window by more than 16 hours. The facility's policy clearly states that any suspected or confirmed abuse must be reported within two hours via the DPH portal, which was not adhered to in this case. The resident involved, admitted in May 2023, had diagnoses including cerebral infarction (stroke) and adjustment disorder with depressed mood. The DON conducted an interview with the resident on the same day of the incident, where the resident confirmed that the CNA had previously taken away the call light, citing 'time-out' as the reason. Despite substantiating the abuse allegation on the same day, the DON delayed reporting the incident to the DPH until the next morning. This delay in reporting constitutes a failure to comply with the facility's abuse policy and federal regulations, thereby compromising the resident's safety and well-being.
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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