Regalcare At Glen Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Massachusetts.
- Location
- 120 Murray Street, Medford, Massachusetts 02155
- CMS Provider Number
- 225523
- Inspections on file
- 21
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Regalcare At Glen Ridge during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses was admitted and assessed as being at risk for elopement, displaying exit-seeking and wandering behaviors. Despite facility policy requiring a baseline care plan within 48 hours, no such plan or interventions were documented prior to the resident's elopement. The DON confirmed that the required care planning was not completed as per policy.
A resident in an LTC facility was physically and emotionally abused by a contracted podiatrist who began clipping the resident's toenails while they were asleep. The resident, who was cognitively intact, woke up startled and told the podiatrist to stop, leading to a physical altercation where the resident was struck, resulting in injuries. The resident expressed ongoing fear and anxiety about the podiatrist's presence, and the podiatrist's account of the incident was inconsistent.
A resident with an ileostomy was found without an ostomy appliance, leading to fecal contamination of their abdominal wound. Despite physician's orders for ileostomy care every shift, the resident's abdomen and incision were covered in fecal matter, and the incision had dehisced. The nurse on duty was aware of the missing appliance but did not assess the resident until prompted by the physician. Temporary supplies were available but not used until after the physician's assessment. The resident was transferred to the hospital for further care.
The facility failed to provide adequate ADL assistance, resulting in two residents developing pressure ulcers due to prolonged incontinence, a resident left unattended during meals despite needing assistance, and two residents not receiving necessary grooming care. Staff shortages and lack of adherence to care plans were cited as contributing factors.
The facility failed to provide adequate wound care and treatment for several residents, resulting in untreated wounds and delayed healing. Staff did not identify or address deteriorating skin injuries, failed to obtain necessary tests, and did not complete physician-ordered treatments. Communication lapses with healthcare providers further exacerbated these issues.
The facility failed to prevent and treat pressure ulcers for several residents, leading to the development and worsening of wounds. One resident developed an unstageable deep tissue injury due to lack of preventive measures, while another's stage II ulcer deteriorated due to unimplemented treatment recommendations. Additionally, a resident was left in soiled briefs for extended periods, resulting in multiple stage II wounds. The facility also failed to notify medical staff about new wounds and did not provide appropriate treatment for a resident's calf wound.
The facility failed to notify physicians of changes in medical status for several residents, leading to deficiencies in care. A resident experienced worsening pain due to unavailable medication, and the physician was not informed. Another resident's wound culture was delayed due to a lack of kits, and the physician was not notified. Additionally, a resident's pressure wound and another's skin injury were not reported to physicians, resulting in inadequate care.
A resident was subjected to abuse during medication administration when a nurse attempted to force-feed medications without communication. Additionally, two residents experienced neglect due to a lack of incontinence care for 17 hours, resulting in pressure ulcers. The facility's inadequate staffing contributed to the neglect, as staff admitted they could not meet the care needs of all residents.
A resident with multiple health issues, including neuropathy, developed a contracture that was not identified or addressed by the facility. Despite a podiatry note indicating limited range of motion, the facility failed to notify the physician or update the care plan. The occupational therapist was unaware of the contracture, and no physical therapy evaluation was conducted. Staffing shortages and lack of a Director of Rehabilitation contributed to the oversight.
A resident with Marfan Syndrome and muscle contracture experienced worsening pain due to inadequate pain management upon admission and when scheduled medication ran out. The facility delayed applying Fentanyl patches for 19 hours and failed to administer a required patch, resulting in severe pain without notifying the physician or providing alternative pain management.
A facility failed to provide sufficient staffing on a nursing unit, resulting in inadequate care for residents. Staffing levels were below budgeted amounts, and staff reported difficulties in maintaining adequate coverage due to frequent call-outs. On the day of the survey, only one nurse and one CNA were available for 24 residents, leading to residents being left in soiled briefs and developing pressure areas. The facility's failure to maintain adequate staffing levels directly contributed to these care deficiencies.
The facility failed to maintain an effective infection prevention and control program. A stained ceiling tile in the laundry room posed a contamination risk. Two residents did not receive proper enhanced barrier precautions during care, and nursing staff did not adhere to hand hygiene protocols during medication administration. These deficiencies were confirmed through observations and staff interviews.
The facility failed to implement person-centered care plans for several residents, leading to deficiencies in care. A resident at high risk for pressure ulcers was observed without required heel offloading, while another was without heel boots despite care plans. Additionally, a resident was not monitored for weight as required, and another was not wearing protective gear as ordered. These observations indicate a lack of adherence to care plans and documentation of resident refusals.
The facility failed to implement a physician's order for two residents, resulting in deficiencies. One resident's significant weight change was not reported to the NP or MD, despite a physician's order. Another resident's Stage 2 wound was not treated or reported to the physician, with the wound remaining uncovered and undocumented in the medical record. The DON confirmed the wound required a medicated dressing, but it was initially misassessed as a scab by a corporate nurse.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple units. The medication room was also found unlocked, and opened insulin pens lacked proper labeling. Additionally, a nurse left a medication cup and an uncapped insulin syringe unattended, accessible to residents. Staff interviews confirmed these actions violated facility policies.
The facility failed to accurately document and manage care for several residents, including improper documentation of pressure injuries, failure to follow physician orders for dialysis care, and inaccurate treatment records for pressure ulcer prevention. Observations and staff interviews revealed discrepancies in care provided versus documented, highlighting significant deficiencies in resident management.
The facility failed to provide a dignified dining experience for two residents, with one experiencing delayed meal service and another not receiving appropriate assistance during meals. Additionally, meals were served on institutional trays, lacking a homelike atmosphere. Privacy was also compromised for a resident during toileting, as they were left exposed and visible to others.
A facility failed to obtain informed consent for psychotropic medications for a resident with Alzheimer's, depression, and lymphedema. Despite policy requirements, the resident's medical record lacked consent documentation for Sertraline, Lorazepam, and Olanzapine, which were administered as ordered. Staff interviews confirmed the necessity of obtaining consent prior to medication administration.
A resident with multiple health conditions, including severe obesity, has not received a shower since admission due to the facility's failure to provide a suitable shower chair. Despite the resident's intact cognition and dependency on staff for all tasks, and repeated requests for assistance, the facility did not accommodate the resident's needs. Interviews with staff revealed a lack of awareness and communication about the issue, and no effective action was taken to resolve the resident's concerns.
A facility failed to ensure consistent documentation of a resident's Advance Directives, resulting in a discrepancy between the MOLST indicating DNR/DNI and the physician's orders stating Full Code. The resident, with Alzheimer's and cognitive impairment, had conflicting documentation, which was confirmed by staff interviews.
The facility did not inform two residents about their potential financial liability for non-covered services under Medicare. The SNFABN form used by the facility failed to include the cost of rehab services, only indicating costs for room and board. This oversight was confirmed by the MDS Nurse during an interview.
A resident with Alzheimer's and dementia was found with pillows under the fitted sheet, restricting movement, without proper assessment or documentation. Facility staff had differing views on whether the pillows were restraints, but the DON confirmed they should not be used this way.
A resident with depression and anxiety reported intentions of self-harm and alleged being beaten by staff, but the DON was not informed, preventing an investigation and state reporting.
Two residents in a LTC facility experienced neglect in incontinence care, with one resident left in a saturated brief for 17 hours, resulting in a new stage one pressure area. Another resident was found with multiple stage II wounds after wearing two saturated briefs for 17 hours. Despite acknowledging the neglect, the facility failed to report the incidents to the state agency within the required timeframe.
Two residents in the facility were found in saturated incontinent briefs, having not received care for 17 hours, leading to skin breakdown and pressure ulcers. Despite the facility's policy requiring regular incontinence care and repositioning, these actions were not taken, and no investigation was initiated. Staff interviews confirmed the neglect, but the facility failed to produce an investigation report.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in their assessments. One resident's MDS incorrectly indicated the use of non-invasive mechanical ventilation, another resident's significant weight loss was not documented, and a third resident's discharge status was inaccurately recorded. These errors were confirmed through interviews and record reviews.
A facility failed to create a baseline care plan for a resident requiring dialysis three times a week, despite the resident's severe cognitive impairment and dependence on renal dialysis. The care plan was not developed until five months after admission, as confirmed by the DON and a Corporate Nurse.
The facility failed to update care plans for three residents, leading to discrepancies in their care. A resident's sleep apnea care plan was not revised after discontinuing CPAP use. Another resident's dialysis care plan was incomplete and delayed by five months. Additionally, a resident's care plan inaccurately required total care for eating, despite being able to eat independently.
A resident with moderate cognitive deficits and vision needs was not provided routine vision services for new eyeglasses. Despite a consent and doctor's order for optometry consultation, the resident had not been seen by an eye doctor, leading to the use of two pairs of glasses for reading and watching TV. Staff interviews revealed a lack of awareness and follow-through in addressing the resident's vision needs.
A resident with hemiplegia and legal blindness, identified as high risk for falls, fell while reaching for snacks. The fall was not reported or assessed by nursing staff until the following day, violating the facility's fall protocol. The incident was discovered when a CNA noticed abrasions on the resident's back during rounds.
The facility failed to maintain nutritional status for two residents, leading to significant weight loss and inadequate dietary management. One resident experienced a 23.98% weight loss without timely intervention, and the facility did not obtain weekly weights as ordered. The resident's dislike of the facility's food was not addressed, and the RD did not evaluate the resident promptly. Another resident, receiving nutrition via a feeding tube, did not receive a timely RD consult as ordered, and weight records were inconsistent. Communication lapses among staff contributed to these deficiencies.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. A resident with chronic respiratory conditions was observed with unchanged oxygen tubing for several months, contrary to expectations for weekly changes. Another resident received incorrect oxygen levels and had undated tubing initially. Staff interviews confirmed the need for weekly tubing changes and adherence to physician orders, which were not followed.
A resident with ESRD requiring dialysis three times a week did not receive appropriate care at the facility. The resident's blood pressure was incorrectly taken from the arm with a dialysis fistula, and a complete care plan was not developed until five months after admission. Additionally, nursing staff failed to consistently follow physician orders for monitoring dialysis access sites, as evidenced by missing documentation in the TAR.
A facility failed to create a trauma-informed care plan for a resident with PTSD, despite the resident's severe cognitive deficits and need for substantial assistance. The care plan lacked individualized interventions and identified triggers, contrary to the facility's policy. Staff interviews confirmed the necessity of such a plan for residents with PTSD.
The facility failed to timely address pharmacy recommendations for two residents. One resident continued receiving an incorrect dosage of metoprolol succinate despite recommendations to adjust it. Another resident had duplicate Tylenol orders and ibuprofen administration instructions that were not updated promptly. These issues persisted for several months before being addressed.
A facility failed to limit the duration of a PRN psychotropic drug for a resident with severe cognitive impairments. The resident was prescribed Lorazepam for anxiety without a stop or re-evaluation date, contrary to facility expectations. Interviews with staff confirmed the oversight.
The facility did not offer pneumonia vaccinations to two residents as required by their policy. One resident admitted in April 2024 had no documentation of receiving, declining, or contraindication for the vaccine, and their MIIS record showed it was due but not given. Another resident admitted in July 2021 also lacked documentation, and their MIIS record was not provided. The Infection Preventionist and Corporate Nurse confirmed that the electronic medical records did not reflect the vaccine status.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline plan of care within 48 hours of admission for one resident. The facility's policy required a baseline care plan to be created within 48 hours to address the resident's immediate needs. The resident in question was admitted with multiple diagnoses, including diabetes, vascular dementia, chronic kidney disease, and dysphagia. Upon admission, the resident was assessed by nursing as being at risk for elopement, exhibiting behaviors such as exit seeking, wandering, and disorientation. However, the section of the Elopement Risk Evaluation intended for documenting interventions and care planning was left blank. Further review of the resident's care plan report and medical record showed that no baseline plan of care or interventions were documented prior to the resident's elopement from the facility. The Director of Nursing confirmed that a baseline plan of care, including an elopement plan, should have been developed within 48 hours of admission but was not completed in this case.
Resident Abused by Contracted Podiatrist
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a contracted podiatrist. The incident occurred when the podiatrist began providing care to the resident's feet while the resident was asleep. Upon waking abruptly, the resident was startled and told the podiatrist to stop, leading to a verbal and physical altercation. During this altercation, the resident was struck on the left side of the face and left arm, resulting in injuries that required evaluation at a hospital emergency department. The resident, who was cognitively intact with a BIMS score of 15/15, expressed fear and anxiety following the incident, particularly concerning the podiatrist's presence in the facility. The resident's medical history included dementia, insomnia, and anxiety, which may have contributed to the heightened emotional response. The resident consistently reported the incident to various parties, including the facility staff, police, and during a psychological evaluation, indicating a significant impact on their sense of safety and well-being. The podiatrist's account of the incident was inconsistent, with conflicting statements provided to the police and during interviews. The podiatrist admitted to attempting to clip the resident's toenails without ensuring the resident was awake or aware of his presence, which led to the resident being startled and the subsequent altercation. The Director of Nurses noted the resident's injuries were new and consistent with the resident's account, although she did not witness the incident herself.
Failure to Provide Appropriate Ileostomy Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an ileostomy, resulting in contamination of the resident's abdominal wound with fecal matter. The resident, who had been admitted with an intestinal obstruction and ileostomy, was found without an ostomy appliance in place, despite having physician's orders for ileostomy care every shift. On the day of the incident, the physician discovered that the resident's abdomen, dressing, and abdominal incision were covered in fecal matter, and the gauze within the incision was soaked. The peristomal skin was red and inflamed, and the abdominal incision had dehisced. Nurse #2, who was aware of the missing ostomy appliance since the beginning of her shift, did not assess the resident's abdomen or stoma until prompted by the physician. Although specific ostomy supplies had not been delivered, temporary supplies were available in the facility but were not used until after the physician's assessment. The Director of Nurses confirmed that the resident should have had an ostomy appliance in place to protect the abdominal incision from fecal contamination. The resident was subsequently transferred to the hospital for further care due to the high risk of infection.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to significant deficiencies in care. For two residents, the facility did not provide timely incontinence care, resulting in them remaining in soiled briefs for 17 hours. This neglect led to the development of pressure ulcers, with one resident developing three Stage II wounds, which were observed to have progressed to Stage III due to the presence of slough. The staff cited insufficient personnel as the reason for the lack of care, as both residents required assistance from two staff members for repositioning and incontinence care. Another resident, who required supervision or assistance with meals, was repeatedly left unattended with meal trays, unable to initiate eating due to their condition. Observations over several days showed that the resident's meal trays were left untouched, and no staff were present to assist, despite the care plan indicating the need for supervision during meals. This lack of assistance could potentially lead to nutritional deficiencies and other health issues. Additionally, the facility failed to provide necessary grooming care for two residents, who were observed with long, dirty fingernails, and another resident who had not received facial hair removal. Despite the care plans indicating the need for assistance with grooming, these tasks were not performed, and there was no documentation of any refusal of care by the residents. Interviews with staff revealed a lack of awareness and follow-through on these grooming needs, further highlighting the facility's failure to adhere to its own care policies.
Deficiencies in Wound Care and Treatment Implementation
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, leading to deficiencies in maintaining their highest practicable well-being. For one resident, the staff did not identify and address a deteriorating skin injury, resulting in a wound with slough and delayed healing. The physician noted that the dressing was undated, saturated, and visibly soiled, indicating it had not been changed for an unknown period, putting the resident at risk for infection. Despite the physician's orders, there was no documentation of treatment implementation until much later. Another resident did not receive a culture and sensitivity test as ordered by the physician for ten days, and the facility failed to notify the physician of their inability to fulfill the order due to a lack of culture kits. This delay in obtaining the necessary test resulted in a deterioration of the resident's wound condition, as noted by a nurse practitioner. The facility's records showed multiple instances where the order was not completed, and there was no documentation of communication with the physician regarding the delay. Additional deficiencies were noted for other residents, including the failure to monitor and treat a stage 2 calf wound, complete physician-ordered wound treatments, and implement treatment orders for a skin tear. In several cases, the facility's staff did not document refusals of treatment or notify physicians of changes in residents' conditions, leading to untreated wounds and potential risks for infection. These failures highlight significant lapses in the facility's adherence to care protocols and communication with healthcare providers.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure ulcers for several residents. For one resident, the facility did not implement necessary interventions to prevent pressure ulcer development, resulting in an unstageable deep tissue injury on the right heel. The care plan lacked specific pressure ulcer prevention measures, and the resident was observed without the prescribed Prevalon boot, with heels directly on the mattress, and with visible signs of wound deterioration. The facility also failed to notify the wound nurse practitioner and the physician about the deteriorating condition of the wounds. Another resident experienced a deterioration of a stage II pressure ulcer to an unstageable ulcer due to the facility's failure to implement the wound nurse practitioner's treatment recommendations. Despite multiple recommendations for specific wound care treatments, the facility did not follow through with the prescribed interventions, leading to the worsening of the resident's condition. The resident expressed non-compliance with wearing booties, but the facility did not document or address this issue adequately. Additionally, the facility did not provide timely incontinence care for a resident, resulting in the development of pressure ulcers. The resident was left in soiled briefs for extended periods, leading to skin breakdown and the formation of multiple stage II wounds. The facility's documentation did not reflect the provision of necessary care, and staff interviews revealed a lack of awareness and adherence to care protocols. The facility also failed to notify the physician or wound nurse practitioner about new wounds, and there was a lack of appropriate wound treatment and documentation for another resident with a calf wound.
Failure to Notify Physicians of Changes in Resident Conditions
Penalty
Summary
The facility failed to notify physicians of changes in medical status for several residents, leading to deficiencies in care. For Resident #78, the facility did not inform the physician when pain medication was unavailable upon admission and when scheduled pain medication ran out, resulting in worsening pain. The resident experienced significant pain due to the lack of medication, and the facility's records did not indicate that the physician was notified of these issues. Interviews with staff revealed that the admitting nurse should have discussed pain management with the physician, but this was not documented. Resident #42's physician was not notified when the facility was unable to fulfill an order to obtain a culture and sensitivity of a new wound for over a week. The resident had a history of multiple sclerosis and chronic venous hypertension with an ulcer on the right lower extremity. Despite the order for a wound culture, the facility ran out of the necessary kits, and the physician was not informed of the delay. This lack of communication resulted in a delay in obtaining the culture and addressing the resident's wound condition. For Resident #81, the facility did not notify the physician or nurse practitioner of a Stage 2 pressure wound on the left calf. The resident, who had a primary diagnosis of stroke and was at risk for pressure injuries, was observed with an open wound that was not reported to the physician. Similarly, Resident #30's deteriorating wounds and the recommendations of the wound nurse practitioner were not communicated to the physician in a timely manner. Lastly, Resident #99's physician was not alerted to a skin injury, and the nurse responsible for the resident's care did not notify the physician due to a lack of awareness of the requirement.
Abuse and Neglect in Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to protect Resident #5, who is cognitively impaired, from abuse during medication administration. A surveyor observed Nurse #3 attempting to administer oral medications to Resident #5 by squeezing the resident's cheeks and trying to force open their mouth with a plastic spoon. This action was taken without any communication or explanation to the resident, who was observed resisting the medication. The nurse admitted to not being familiar with the resident's medication needs and acknowledged that her actions were inappropriate. Residents #63 and #10 were subjected to neglect as they did not receive incontinence care for 17 hours, leading to the development of pressure ulcers. Resident #63, who is dependent on staff for all functional tasks, was found in bed with two saturated incontinence briefs, resulting in skin excoriation and the development of stage II wounds. The resident reported that they requested two briefs because staff did not change them regularly. Similarly, Resident #10, who is also dependent on staff for toileting needs, was found in a saturated brief with a new stage one pressure area on the coccyx. The facility's failure to provide adequate staffing and care for residents requiring assistance with incontinence care and repositioning was highlighted by the staff's admission of insufficient personnel to meet the needs of all residents. The lack of timely care and repositioning contributed to the residents' discomfort and the development of pressure ulcers, indicating neglect in adhering to the facility's care protocols.
Failure to Address Newly Developed Contracture in Resident
Penalty
Summary
The facility failed to identify and address a newly developed contracture in a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including morbid obesity, diabetes, and neuropathy, was observed to have limited passive range of motion and contractures in the lower extremities during a podiatry visit. However, these findings were not documented in the resident's admission nursing assessment or the occupational therapy evaluation. The resident was dependent on staff for all functional tasks and had intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status exam. Despite the podiatry note indicating limited range of motion and contractures, the facility did not notify the physician or update the resident's care plan. Interviews revealed that the occupational therapist was unaware of the contracture, and there was no physical therapy evaluation on file since admission. The facility lacked a Director of Rehabilitation and was short-staffed, contributing to the oversight. The corporate nurse confirmed that new contractures should trigger a change in condition protocol, but this was not followed, resulting in a failure to address the resident's needs adequately.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident upon admission, resulting in the resident experiencing worsening pain for 19 hours without any medication being administered. The resident, who has a history of Marfan Syndrome and muscle contracture, was admitted with a discharge order for Fentanyl patches to manage chronic pain. However, the facility did not apply the Fentanyl patch until nearly 19 hours after admission, during which time the resident was in significant pain and requested to be transferred back to the hospital. Additionally, the facility failed to manage the resident's pain effectively when the scheduled pain medication ran out. The resident was supposed to have three Fentanyl patches applied, but the facility ran out of one of the patches, and it was not administered as ordered. The resident reported a pain level of 10 out of 10, indicating severe pain, but there was no documentation of the physician being notified or alternative pain management being provided. Interviews with the nursing staff revealed that the nurse on each shift is responsible for monitoring medication supplies and reordering them when low. However, in this case, the nurse did not notify the physician or document a plan for pain management while waiting for the medication to arrive. The facility's emergency medication supply system was not accessed to provide any pain medication for the resident during this time.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents on one of its nursing units, resulting in inadequate care for multiple residents. The staffing plan outlined in the Facility Assessment Tool indicated a need for 16-18 licensed nurses and 20-28 nurse aides per day, with specific nurse-to-resident and CNA-to-resident ratios. However, the facility's Hours Per Patient Day (HPPD) report showed that staffing levels were below budgeted amounts for 12 out of the previous 30 days. Interviews with staff, including the Scheduling Coordinator and various nurses, revealed difficulties in maintaining adequate staffing, particularly during the 7:00 A.M. to 3:00 P.M. shift, due to frequent call-outs and insufficient staff coverage. On the day of the survey, only one nurse and one CNA were available to care for 24 residents on the unit until a second CNA was floated to the unit at 11:00 A.M. This staffing shortage led to significant care deficiencies, as observed by the surveyors. Nurse #9 and CNA #4 reported being unable to provide necessary care, including medication administration, treatments, and incontinence care, due to the overwhelming workload. As a result, residents were left in soiled briefs for extended periods, and some required assistance from two staff members, which was not available. The Director of Nursing and Corporate Nurse #1 acknowledged the staffing issues and the impact on resident care. The inadequate staffing resulted in residents developing pressure areas and skin breakdowns. Resident #63 was found wearing two soiled incontinent briefs, with excoriation and open ulcers on the buttocks and thigh, indicating a lack of timely incontinence care. Similarly, Resident #10 was observed with a saturated brief and a new stage one pressure area on the coccyx. Staff interviews confirmed that these residents had not received the necessary care due to the insufficient number of staff available to assist with repositioning and other care needs. The facility's failure to maintain adequate staffing levels directly contributed to the observed deficiencies in resident care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the laundry room, a stained and potentially moldy ceiling tile was found above a bin of clean clothing, with water occasionally dripping from it. The Director of Laundry Services and Laundry Staff were unaware of the duration of the leak, and the Maintenance Director expressed concern about possible contamination of clean clothing due to the leak. For Resident #30, who has schizoaffective disorder, dementia, and heart failure, the facility did not implement enhanced barrier precautions (EBP) during the treatment of an open wound. The resident was observed with an open heel wound, and staff entered the room without donning the required gown, failing to follow EBP protocols. Similarly, for Resident #45, who has cerebral infarction and a feeding tube, staff did not use personal protective equipment (PPE) during care, and there was no EBP sign on the resident's door, contrary to the care plan. Additionally, the facility's nursing staff did not adhere to hand hygiene protocols during medication administration. Observations included nurses failing to perform hand hygiene after removing gloves, touching contaminated items, and handling medications. Interviews with the nurses and management confirmed the lapses in infection control practices, with acknowledgments that hand hygiene should have been performed as per facility policy.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement person-centered care plans for six residents, leading to deficiencies in care. Resident #3, who was at high risk for developing pressure ulcers, was observed multiple times with heels directly on the mattress, contrary to the care plan that required offloading heels while in bed. Despite the care plan and high-risk score on the Norton Plus Pressure Ulcer Scale, staff were unaware of the requirement, and the resident's heels were not offloaded as needed. Resident #28, also at high risk for pressure ulcers, was observed without heel boots on several occasions, despite physician orders and a care plan specifying their use while in bed. The nursing progress notes did not document any refusal of the heel boots by the resident, indicating a failure to follow the care plan. Similarly, Resident #30, with a history of pressure areas, was observed without Prevalon boots, and no documentation indicated a refusal, highlighting a lack of adherence to the care plan. Additional deficiencies were noted for Resident #99, who was observed without a pillow between the legs and with only one floor mat, despite care plan requirements. Resident #100's care plan required weekly weight monitoring due to nutritional risks, but weights were not consistently recorded. Lastly, Resident #90, with severe cognitive impairment, was not wearing Geri sleeves or Prevalon boots as ordered, and there was no documentation of refusal, indicating a failure to implement the care plan effectively.
Failure to Implement Physician's Orders and Report Wounds
Penalty
Summary
The facility failed to implement a physician's order for two residents, leading to deficiencies in care. For one resident, the facility did not report a significant weight change to the Nurse Practitioner (NP) or Medical Doctor (MD) as required by the physician's order. The resident's weight increased from 123 lbs to 143.6 lbs within a day, which was a change greater than the 3 lbs threshold that necessitated notification. Interviews with the MD, a nurse, and the Director of Nurses (DON) confirmed that the weight change was not communicated, and no nursing progress note was written to document the notification. For another resident, the facility failed to treat and accurately report a Stage 2 wound to the physician. The resident, who was at risk for pressure injuries, was observed to have a 1 cm x 1 cm wound on the left calf, which was not covered with a dressing. The wound was initially identified by a nurse and later confirmed by a unit manager and the DON as a Stage 2 pressure injury. However, the wound was not documented in the resident's medical record, and there was no evidence that the physician or NP was notified or that a treatment order was obtained. The corporate nurse initially assessed the wound as a scab and did not report it to the physician, leading to a lack of appropriate treatment. The DON later confirmed that the wound was not a scab and required a medicated dressing. Despite the assessment indicating a treatment was applied, the wound remained uncovered, and there was no documentation of physician notification or treatment orders in the resident's medical record.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and in accordance with professional standards. On multiple occasions, medication carts on the Oak Grove Unit were observed unlocked and unsupervised in the hallway, with no staff present. Similarly, treatment carts on the [NAME] and Maplewood Units were found unlocked and unattended, allowing unauthorized access to medications. Interviews with nursing staff and the Director of Nurses confirmed that these carts should be locked when not in use. Additionally, the medication room on the Oak Grove Unit was found unlocked and unsupervised for an extended period, contrary to the facility's policy that requires such areas to be secured when not in use. Furthermore, opened insulin pens and an antibiotic solution on the [NAME] unit's medication carts lacked proper labeling, including resident names and opening or expiration dates, which is a violation of both state and federal laws. The surveyor also observed unsafe practices involving medication handling. A medication cup containing pills and an uncapped insulin syringe were left unattended on a medication cart and later on a countertop at the nurse's station, with residents nearby. Nurse #3 was seen placing these items in front of a resident and walking away, leaving them accessible. Interviews with the nurse, unit manager, and corporate nurse confirmed that medications and syringes should not be left unattended, and medication carts must be locked at all times.
Documentation and Care Deficiencies in Resident Management
Penalty
Summary
The facility failed to accurately document and manage the care of several residents, leading to deficiencies in their medical records and treatment. For one resident, the facility did not properly document a Stage 2 pressure injury on the left calf, which was observed by multiple staff members and surveyors. Despite the wound being identified, there was no documentation of physician notification or appropriate treatment orders, and the wound remained uncovered during subsequent observations. Another resident, who required Prevalon boots for pressure ulcer prevention, was observed multiple times without the boots, and the treatment sheet inaccurately indicated that the boots were worn. Staff interviews revealed a lack of awareness regarding the resident's need for the boots, and the boots were not found in the resident's room. This discrepancy between the treatment sheet and actual care provided highlights a failure in following physician orders and accurately documenting care. Additionally, the facility failed to consistently follow physician orders for a resident requiring dialysis care. The Treatment Administration Record (TAR) lacked documentation of necessary checks on dialysis access sites and monitoring for complications on several dates. Interviews with nursing staff confirmed that these orders were not followed, as indicated by the absence of documentation. This lack of adherence to physician orders and documentation requirements represents a significant deficiency in the resident's care management.
Deficiencies in Dignity and Privacy for Residents
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, Resident #50 and Resident #30. Resident #50 experienced a delay in meal service, receiving their meal 32 minutes after their tablemates, which caused distress as they had to watch others eat while they remained hungry. Resident #30, who requires supervision and assistance with eating due to dysphagia and moderate cognitive impairment, was not provided with appropriate assistance. A CNA was observed feeding Resident #30 while standing and without engaging with the resident, contrary to the facility's policy of providing assistance at eye level and engaging with residents during meals. The facility also failed to serve meals in a homelike atmosphere on the [NAME] Unit, as observed by the surveyor. Meals were served on institutional trays, and staff were not aware that they were supposed to place the contents of the meal trays onto the table and remove the tray to create a more homelike dining experience. Additionally, the facility failed to provide privacy for Resident #86 during toileting. The resident, who has severe cognitive impairment and is dependent on assistance for toileting, was left exposed in the bathroom with the door open, visible to others in the hallway. This lack of privacy was observed by the surveyor, and staff interviews confirmed that privacy should have been ensured during personal care activities.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for a resident prior to administration. The facility's policy, revised in April 2022, mandates that informed consent from the resident or a legally authorized individual is required before administering psychoactive medication. However, the medical record of a resident admitted in January 2024 with Alzheimer's disease, depression, and lymphedema, did not contain consent for the prescribed psychotropic medications, including Sertraline, Lorazepam, and Olanzapine. The resident's Minimum Data Set indicated a low cognitive score, and the Medication Administration Record for August 2024 showed that Sertraline and Olanzapine were administered daily as ordered. Interviews with facility staff, including a nurse and the Director of Nurses, confirmed that consent should have been obtained prior to administering these medications, but it was not documented in the resident's medical record.
Failure to Provide Adequate Shower Facilities for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident who was admitted with multiple diagnoses, including morbid severe obesity, type two diabetes, and congestive heart failure. The resident, who has intact cognition and is dependent on staff for all functional tasks, has not received a shower since admission due to the lack of a suitable shower chair. Despite the resident's repeated requests and the involvement of the Ombudsman and community care worker, the facility did not provide the necessary equipment to meet the resident's needs. Interviews with various staff members, including nurses, the unit manager, the corporate nurse, and the director of nursing, revealed a lack of awareness and communication regarding the resident's need for a shower chair. The occupational therapist confirmed that the resident requires a large shower chair and is capable of transferring with a hoyer lift, yet no assessment or provision of such equipment was made. The social worker's notes indicated awareness of the resident's concerns, but no effective action was taken to resolve the issue, leading to the resident's prolonged lack of proper hygiene care.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident. The facility's policy requires that advance directives be respected and documented in accordance with state law and facility policy. However, for one resident, there was a discrepancy between the Medical Orders for Life-Sustaining Treatment (MOLST) and the physician's orders. The MOLST indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, while the physician's orders and care plan indicated a Full Code status. The resident, who was admitted with Alzheimer's disease, depression, and lymphedema, had a low score on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. Despite the MOLST reflecting a DNR and DNI, the active physician orders and care plan meeting notes documented the resident as Full Code. This inconsistency was confirmed during interviews with Nurse #6 and the Director of Nurses, who acknowledged that the physician's orders should align with the MOLST. The failure to ensure consistent documentation of advance directives led to a deficiency in the facility's compliance with its policy and state law.
Failure to Inform Residents of Potential Financial Liability
Penalty
Summary
The facility staff failed to inform two out of three residents, or their representatives, about their potential financial liability for non-covered services under Medicare. The Advanced Beneficiary Notice (SNFABN) is intended to provide residents with information to decide whether to continue receiving skilled services that may not be covered by Medicare, thereby assuming financial responsibility. However, the facility's SNFABN form did not include the cost of rehab services for two of the three applicable residents. During an interview, the Minimum Data Set Nurse confirmed that the form only indicated costs for room and board, excluding skilled services such as rehab.
Improper Use of Pillows as Restraints
Penalty
Summary
The facility failed to properly assess and identify the use of pillows under the fitted sheet as a potential restraint for a resident diagnosed with Alzheimer's disease, dementia, aphasia, peripheral vascular disease, and depression. The resident was observed on multiple occasions with two pillows placed under the fitted sheet along the length of the mattress on both sides, which restricted the resident's movement. The facility's policy on the use of restraints, revised in April 2022, clearly states that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully, and only upon a physician's written order with consent from the resident or their representative. Despite these guidelines, the resident's medical record lacked documentation of a restraint assessment, a physician's order, consent for restraint use, and a care plan for a restraint. Interviews with facility staff, including a nurse, unit manager, corporate nurse, and the Director of Nursing, revealed differing opinions on whether the pillows constituted a restraint. The nurse believed the pillows were necessary to prevent the resident from falling, while the unit manager and corporate nurse acknowledged that the pillows were a restraint and should not be used in this manner. The Director of Nursing confirmed that placing pillows under the fitted sheet is considered a restraint and emphasized the need for proper assessment.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to effectively implement its abuse policy regarding the reporting of alleged abuse for one resident. The policy, dated March 2022, mandates the investigation of all alleged incidents of resident abuse, neglect, mistreatment, injuries of unknown etiology, and misappropriation of property. A resident, admitted in May 2024 with diagnoses of depression and anxiety, reported to a nurse on September 17, 2024, that they intended to harm themselves due to the conditions at the facility and alleged being beaten by staff during changes. Despite this report, the Director of Nursing was not informed of the alleged abuse, preventing the initiation of an investigation and the reporting of the incident to the state agency.
Neglect in Incontinence Care and Reporting Failures
Penalty
Summary
The facility failed to report allegations of neglect related to incontinence care for two residents to the state agency as required. Resident #10, who was admitted with diagnoses including pain, spinal stenosis, and osteoarthritis, was found in a saturated incontinent brief that had not been changed for 17 hours. The resident, who is totally dependent on staff for toileting needs, was observed with a new stage one pressure area on the coccyx. The Unit Manager acknowledged the neglect and attributed it to insufficient staffing, as only one CNA and one nurse were available to care for 24 residents requiring assistance. Resident #63, admitted with multiple diagnoses including morbid obesity, type two diabetes, and congestive heart failure, also experienced neglect in incontinence care. The resident, who is dependent on staff for all functional tasks, was found wearing two saturated incontinent briefs after 17 hours without care. The resident had dried feces on the skin and multiple stage II wounds, which were incorrectly identified as stage III due to the presence of slough. The Corporate Nurse and other staff confirmed the neglect and the expectation for residents to receive care every two hours. Despite acknowledging the neglect, the Corporate Nurse did not report the incidents to the state agency. The facility's policy requires reporting such allegations within 24 hours if they do not result in serious bodily injury. The neglect was only reported to the Department of Public Health six days after the facility was notified of the allegations, indicating a failure to comply with mandatory reporting requirements.
Failure to Investigate Allegations of Neglect for Two Residents
Penalty
Summary
The facility failed to investigate allegations of neglect for two residents, as required by their policy. Resident #10, who was admitted with diagnoses including pain, spinal stenosis, and osteoarthritis, was found in a saturated incontinent brief that had not been changed for 17 hours. This neglect was observed by a surveyor and Unit Manager #1, who noted a new stage one pressure area on the resident's coccyx. Despite being informed of the situation, the facility did not initiate an investigation into the alleged neglect. Resident #63, admitted with multiple diagnoses including morbid obesity and type two diabetes, was also found in a similar state of neglect. The resident was wearing two saturated incontinent briefs and had not received incontinence care for 17 hours. Observations revealed excoriation and multiple stage II wounds, which were not properly addressed. Despite the facility's policy requiring repositioning and incontinence care every two hours, these actions were not taken, and no investigation was initiated. Interviews with facility staff, including Corporate Nurse #1 and the Director of Nurses, confirmed that the lack of incontinence care for 17 hours constituted neglect. The facility's failure to investigate these incidents of neglect for both residents was noted by the surveyor, and no investigation report was produced by the time of the survey exit.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. For one resident, the MDS inaccurately indicated the use of non-invasive mechanical ventilation, despite the discontinuation of the CPAP machine in April 2024, as confirmed by nursing progress notes and interviews with the nursing staff. Another resident experienced a significant weight loss of 32.4 pounds, or 15.93%, over two months, which was not reflected in the MDS. This discrepancy was acknowledged by the MDS Nurse during an interview. Additionally, the MDS for a third resident inaccurately documented the discharge status, stating the resident was discharged home, whereas the resident had been sent to the hospital for evaluation following a fall. This error was also confirmed by the MDS Nurse. These inaccuracies in the MDS coding highlight a failure in ensuring accurate assessments for the residents, as evidenced by the interviews and record reviews conducted during the survey.
Failure to Develop Timely Dialysis Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for providing effective and person-centered care for a resident requiring dialysis three times a week. The resident, admitted in February 2024, had diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease, End Stage Renal Disease (ESRD), and dependence on renal dialysis. Despite the resident's severe cognitive impairment, as indicated by a score of 3 out of 15 on the Brief Interview for Mental Status exam, the facility did not create a baseline care plan for dialysis until July 2024, five months after admission. This omission was confirmed during an interview with the Director of Nursing and a Corporate Nurse, who acknowledged that a dialysis care plan should have been part of the baseline care plan upon admission.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised with the interdisciplinary team as required for three residents. For Resident #28, the care plan for sleep apnea was not updated despite the discontinuation of the CPAP machine, which was noted in a nursing note and confirmed by the Director of Nurses. The resident, who is cognitively intact, had refused the CPAP machine, and the physician had approved its discontinuation, yet the care plan still listed CPAP as ordered. Resident #16's care plan was not revised to include a dialysis plan of care upon admission or during the initial comprehensive assessment. The resident, who has severely impaired cognition and requires dialysis three times a week, had a dialysis care plan created five months after admission. The care plan was incomplete, lacking specific interventions and details about the dialysis schedule and site protection, which was acknowledged by the Director of Nursing and Corporate Nurse. For Resident #77, the care plan was not updated to reflect the resident's current ability to eat independently. Despite observations of the resident eating alone and a CNA confirming that the resident only requires setup help for eating, the care plan still indicated that the resident requires total care for eating. This discrepancy was not addressed in the care plan, which had not been revised since the previous intervention update.
Failure to Provide Routine Vision Services
Penalty
Summary
The facility failed to provide routine vision services to a resident who required new eyeglasses. The resident, who was admitted in November 2023, had diagnoses including hemiplegia and diabetes mellitus, and demonstrated moderate cognitive deficits with a BIMS score of 8. The resident required assistance for self-care activities and had adequate vision with corrective lenses. Despite signing a consent to see optometry and having a doctor's order for an ophthalmology consultation in November 2023, the resident had not been seen by an eye doctor by August 2024. The resident was observed wearing two pairs of glasses simultaneously to read and watch television, indicating a need for updated vision services. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's vision needs. Nurse #4 stated that the process for scheduling an eye doctor appointment involves the nurse reaching out to the consultant service and the unit manager ensuring the resident is on the appointment list. However, Nurse #4 was unaware of the resident's use of two pairs of glasses. Corporate Nurse #1 emphasized the responsibility of the entire team to make referrals for new glasses when needed. The facility's vision services records confirmed that the resident had not been seen by an eye doctor, highlighting a deficiency in providing necessary vision care.
Failure to Initiate Timely Falls Assessment and Investigation
Penalty
Summary
The facility failed to ensure timely initiation of a falls assessment and investigation following a fall with injury for a resident. The resident, who has diagnoses including hemiplegia, hemiparesis, and legal blindness, was identified as being at high risk for falls. Despite this, after the resident fell while attempting to reach a container of cheese balls, no immediate nursing assessment or falls investigation was conducted. The resident reported the fall occurred when they stood up from their wheelchair and lost balance, resulting in abrasions on their back. The incident was only discovered the following morning when a CNA noticed the injuries during rounds. The facility's policy requires that all accidents involving residents be investigated and reported to the administrator. However, in this case, the staff member who found the resident did not notify a nurse, and no assessment was performed before the resident was assisted off the floor. The Director of Nursing and Corporate Nurse confirmed that a falls investigation was not initiated as they were unaware of the incident until the morning after it occurred. This lack of timely response and documentation represents a deficiency in the facility's adherence to its fall protocol and accident investigation procedures.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant deficiencies in their care. Resident #103 experienced a significant weight loss of 23.98% since admission, which was not addressed in a timely manner. The facility did not obtain weekly weights as ordered, with only 5 out of the 18 required weights recorded. Additionally, the resident's dislike of the facility's food was known but not adequately addressed, as the Food Service Director was not informed of the resident's preferences. The Registered Dietitian (RD) did not evaluate the resident promptly after a significant weight loss was recorded, with the first evaluation occurring over two months later. Resident #45, who was admitted with severe cognitive impairments and received nutrition via a feeding tube, also experienced deficiencies in care. The facility failed to obtain a Registered Dietitian consult as ordered by the physician. The resident's weight was not consistently recorded, with no weight documented for June 2024, and the RD did not follow up after a weight loss was noted in July. The RD was not alerted to the need for a consult due to a lack of communication from the Director of Nurses, who was responsible for notifying the RD of such orders. Interviews with facility staff revealed systemic issues in communication and adherence to protocols. The RD, who worked remotely, was not informed of significant weight changes or the need for consultations in a timely manner. The Director of Nursing and Corporate Nurse acknowledged that residents with orders for weekly weights should be weighed accordingly, and any significant weight loss should prompt immediate re-evaluation and notification of the RD and physician. The Food Service Director was unaware of Resident #103's food preferences due to a lack of communication from the nursing staff.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in the management of their oxygen therapy. Resident #6, who has chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was observed multiple times over several days with oxygen tubing that had not been changed since May 15, 2024. Despite the physician's order for oxygen therapy as needed, there was no specific order for changing the oxygen tubing. Interviews with nursing staff and the Director of Nurses revealed that the expectation was for oxygen tubing to be changed weekly and as needed, but this was not documented in the physician's orders. Similarly, Resident #30, who has dysphagia, dementia, type two diabetes mellitus, and protein-calorie malnutrition, was observed receiving oxygen therapy with tubing that was not dated initially and later dated August 5, 2024. The resident's physician orders specified oxygen at 2 liters per minute, but observations showed the resident receiving 2.5 liters. Interviews with the Unit Manager and Corporate Nurse confirmed that the oxygen tubing should be changed weekly and that the orders should be followed as prescribed by the physician. These observations and interviews highlight the facility's failure to adhere to professional standards of practice for respiratory care.
Deficiency in Dialysis Care for Resident with ESRD
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with End Stage Renal Disease (ESRD) who required dialysis three times a week. The resident, who had severely impaired cognition, was admitted with a dialysis fistula in the left upper extremity and a dialysis catheter in the right upper chest wall. The facility did not consistently obtain the resident's blood pressure from the correct arm, as it was taken from the left arm, where the fistula was located, on nine occasions in the past 30 days, contrary to professional standards of practice. Additionally, the facility did not create a complete and resident-specific care plan for the resident's dialysis care. The care plan was not developed until five months after admission and was incomplete, lacking specific details such as dialysis days and the protection of the access site. The care plan also failed to include comprehensive interventions tailored to the resident's dialysis needs, which should have been established at the time of admission or during the comprehensive quarterly assessment. Furthermore, the facility's nursing staff did not consistently follow physician orders regarding the monitoring of the dialysis access sites. Documentation in the Treatment Administration Record (TAR) showed that nurses failed to check and document the observation of the dialysis access sites, AV fistula, and hemodialysis site for signs of complications on multiple occasions. Interviews with nursing staff and the Director of Nursing confirmed that these orders were not followed, and the necessary documentation was not completed, indicating a lapse in adherence to physician orders and facility protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in March 2024, has severe cognitive deficits and requires substantial assistance for daily activities. Despite having an active diagnosis of PTSD, the resident's care plan did not include individualized interventions or identified triggers related to their condition. Interviews with facility staff, including a nurse, a social worker, and a corporate nurse, confirmed that a care plan should have been developed for residents with PTSD, identifying specific triggers to better care for the resident. The facility's policy on Trauma Informed Care, dated May 2022, outlines the need for nursing staff to be trained on trauma assessment and the identification of triggers, as well as the development of strategies to address these triggers. However, this policy was not effectively implemented for the resident in question.
Delayed Implementation of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two residents. Resident #28, who was admitted with diagnoses including vascular dementia and chronic kidney disease, was receiving metoprolol succinate 25 mg twice a day, despite the pharmacist's recommendation to change the order to metoprolol succinate 50 mg once daily. This recommendation was not implemented, and the resident continued to receive the incorrect dosage as per the physician's orders from December 2023 to August 2024. The Director of Nurses acknowledged that the MMRs for this resident should have been completed but were not. Similarly, Resident #104, admitted with coronary artery disease and diabetes, had pharmacy recommendations for duplicate medication orders and administration instructions that were not implemented in a timely manner. The recommendations included discontinuing duplicate Tylenol orders and updating the administration instructions for ibuprofen to include giving with food or milk. Although the physician signed off on these recommendations, they were not implemented until several months later, in August 2024. Corporate Nurse #1 was aware of the delay in implementing these recommendations.
Failure to Limit PRN Psychotropic Drug Duration
Penalty
Summary
The facility failed to ensure that PRN psychotropic drugs were limited to 14 days for a resident diagnosed with Alzheimer's disease, depression, and lymphedema. The resident, who was admitted in January 2024, had severe cognitive impairments as indicated by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS). A physician's order dated July 17, 2024, prescribed Lorazepam, an anti-anxiety medication, to be administered as needed every 4 hours for anxiety. However, the order did not include a stop date or a re-evaluation date, which is a requirement for such medications. Interviews with Nurse #6 and the Director of Nurses confirmed the expectation that PRN orders for Lorazepam should have a stop and re-evaluation date, which was not present in this case.
Failure to Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that pneumonia vaccinations were offered to two of five sampled residents. According to the facility's policy revised in January 2024, all residents should be assessed for eligibility to receive the pneumococcal vaccine upon admission and offered the vaccine unless contraindicated, refused, or previously vaccinated. Resident #45, admitted in April 2024, had no documented history of receiving, declining, or having a contraindication for the pneumonia vaccine in their electronic medical record. The Massachusetts Immunization Information System (MIIS) record indicated the vaccine was due but not administered. Similarly, Resident #90, admitted in July 2021, also lacked documentation of receiving, declining, or having a contraindication for the vaccine, and the facility did not provide their MIIS record. During an interview, the Infection Preventionist and Corporate Nurse confirmed that if the electronic medical records did not indicate the vaccine status, the information would not be found elsewhere.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
