Regalcare At Harwich
Inspection history, citations, penalties and survey trends for this long-term care facility in Harwich, Massachusetts.
- Location
- 111 Headwaters Drive, Harwich, Massachusetts 02645
- CMS Provider Number
- 225525
- Inspections on file
- 23
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Regalcare At Harwich during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependent on staff for self-care was not treated with dignity when a CNA repeatedly pretended to sit on the resident's lap, despite the resident's verbal protests. The incident was witnessed by another CNA and a family member, resulting in the resident becoming visibly upset.
The facility failed to maintain a clean and homelike environment on the Bayview and Cranview units, with issues such as unpainted areas, broken fixtures, and dirty conditions. Observations revealed chipped flooring, exposed wires, and damaged furniture. Residents' representatives expressed dissatisfaction with the facility's condition. A gap in maintenance coverage contributed to the neglect of these issues.
The facility failed to maintain sanitary conditions and proper temperature monitoring in two kitchenettes. In the Bayview kitchenette, the freezer temperature was not logged, and unsanitary conditions were observed, including sticky drawers and improperly stored food items. In the Cranview Unit, the freezer had significant frost buildup, and ice cream was found soft, with no thermometer or temperature log present. The Food Service Director acknowledged the issues, noting the impact on food quality and safety.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE protocols for residents on droplet and contact precautions. A nurse entered a COVID-19 positive resident's room without full PPE, and an activity assistant entered another COVID-19 positive room without any PPE. Additionally, a housekeeper failed to follow contact precautions for residents with ESBL and C-diff, not wearing a gown or changing gloves between rooms.
A facility failed to obtain a court-approved treatment plan for administering antipsychotic medication to a resident with a legal guardian. Despite being notified of the guardianship, the facility administered Risperidone without the necessary documentation for over 40 days. Staff interviews revealed a lack of understanding of the consent process when a guardian is involved.
A resident with a history of falls and a right femur fracture had a care plan intervention to place a padded floor mat on the left side of the bed. However, observations revealed the mat was consistently found against the wall, not in use as intended. Staff interviews confirmed the mat was not placed on the floor, indicating non-compliance with the care plan.
A resident with Type 2 diabetes and chronic heart failure continued to receive an incorrect potassium chloride dosage due to the facility's failure to act on a consultant pharmacist's recommendation. The pharmacist advised reducing the dosage from 40 meq to 20 meq per day, but this was not communicated effectively to the attending physician and DON, resulting in the resident receiving the higher dosage until the error was discovered over a month later.
A facility failed to maintain accurate medical records, resulting in a discrepancy in the discharge destination for a resident with multiple health conditions. The resident was supposed to be transferred to a local SNF closer to family, as requested by the healthcare proxy, but the physician's order incorrectly listed a different SNF. The Unit Manager admitted the error was due to a transcription mistake.
The facility failed to accurately complete MDS assessments for two residents. One resident's admission date and contracture status were incorrectly documented, while another resident's discharge location was inaccurately coded. MDS nurses acknowledged the errors in the assessments.
Resident Not Treated with Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a resident with dignity and respect. The incident involved a resident with severe cognitive impairment, dementia, and psychotic disorder with delusions, who was dependent on staff for self-care. The CNA engaged in teasing behavior by repeatedly pretending to sit on the resident's lap while the resident was seated on an unoccupied bed in another resident's room. Despite the resident's verbal protests, the CNA continued the behavior multiple times. This interaction was witnessed by another CNA, who confirmed that the resident yelled each time the CNA attempted to sit on their lap and that the behavior was repeated three times. A family member, upon hearing the resident yelling, entered the room and observed the CNA sitting on the resident's lap, which caused the resident to become upset and seek comfort from the family member. The family member described the CNA's behavior as bizarre and inappropriate. The facility's internal investigation corroborated that the CNA's actions were intended as a joke but were not appropriate, especially given the resident's cognitive status and distress during the incident.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the Bayview and Cranview units. Observations revealed numerous issues, including unpainted areas, chipped and discolored moldings, and missing or broken fixtures such as blinds, thermostats, and closet doors. The Bayview unit's breakfast dining room had significant damage, including chipped wood flooring and a scuffed wall. Several resident rooms had exposed wires, broken molding, and discolored ceiling tiles, indicating a lack of maintenance and repair. On the Cranview unit, similar deficiencies were noted, such as a large hole in the residents' shower room wall with exposed wood and crumbled plaster. One resident's room was found to be dirty, with broken furniture and a damaged blind. Additionally, a hallway window was cracked, and the screen was frayed with a hole, further contributing to the unkempt environment. These observations were corroborated by interviews with residents' representatives, who expressed dissatisfaction with the facility's condition, describing it as depressing and in disrepair. The facility experienced a gap in maintenance coverage due to the absence of a full-time Maintenance Director, during which emergent issues were prioritized over routine maintenance. The Regional Plant Manager acknowledged that the neglect of maintenance issues extended beyond the three-week gap. The facility's Administrator confirmed the hiring of a new maintenance director and acknowledged that preventative maintenance was not conducted during the lapse in coverage.
Sanitation and Temperature Monitoring Deficiencies in Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in two out of three kitchenettes, as observed by the surveyor. In the Bayview kitchenette, the refrigerator temperature log lacked a section for freezer temperatures, and no temperatures were recorded for the freezer from the beginning of the month until the survey date. The freezer was found full of small individual ice creams, with the thermometer covered in ice particles, indicating improper storage. Additionally, the kitchenette's counter drawers were sticky, with one containing a brown sticky substance on condiment packets. A baseball-sized tin foil containing a hamburger was found in a cabinet, and an open, undated bottle of ranch dressing, which should have been refrigerated, was also discovered. The Unit Manager was unaware of who was responsible for cleaning the kitchenette and acknowledged that the hamburger and ranch dressing should not have been stored in the cabinets. In the Cranview Unit nourishment kitchen, the surveyor observed a significant frost buildup in the freezer, which contained individual portion-sized ice cream cups and a half-gallon container of ice cream, all of which were soft to the touch. There was no thermometer in the freezer, and no log for monitoring freezer temperatures was maintained. The Food Service Director confirmed that frozen items should not be soft and acknowledged the absence of a thermometer and temperature monitoring log, admitting that improper temperatures could affect food quality and safety.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple instances where staff did not adhere to required personal protective equipment (PPE) protocols. For Resident #24, who tested positive for COVID-19, Nurse #3 entered the room to administer medication without wearing the necessary PPE, including a gown, N-95 mask, and eye protection. Despite the presence of a red isolation sign indicating droplet precautions, Nurse #3 initially wore only a surgical mask and gloves, failing to ensure proper protection against potential transmission. Similarly, for Residents #19 and #82, who were also on droplet precautions due to COVID-19, Activity Assistant #2 entered their room without donning any PPE, despite the red isolation sign posted at the doorway. This oversight occurred while delivering coffee, a snack, and the Daily Chronicle, and the assistant did not perform hand hygiene between resident interactions. The assistant was unaware of the need for PPE, mistakenly believing the residents were no longer positive for COVID-19. Additionally, the facility failed to enforce contact precautions for Residents #16 and #57, who were on contact precautions for ESBL and C-diff, respectively. Housekeeper #2 entered both residents' rooms without wearing a gown and did not change gloves or perform hand hygiene between room entries. This breach of protocol was observed despite clear signage indicating the need for contact precautions, highlighting a lack of adherence to infection control measures by the housekeeping staff.
Failure to Obtain Court-Approved Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain a court-approved [NAME] Treatment Plan for the administration of antipsychotic medication to Resident #24, who was admitted with diagnoses including traumatic brain injury and dementia with behavioral disturbances. Upon admission, the resident's medical record indicated a Health Care Proxy was in effect, but it was later discovered that the resident had a legal guardian with authority to approve antipsychotic treatment. Despite this, the facility administered Risperidone without the necessary [NAME] Treatment Plan, as the guardian was unaware of the resident's location and had limited documentation. The facility was notified of the guardianship in June 2024, but failed to obtain the required treatment plan for over 40 days. The surveyor requested the document on August 8, 2024, but the facility was unable to provide it. Interviews with staff revealed a lack of understanding of the process for obtaining consent when a guardian is involved. The Director of Nurses and the Administrator acknowledged the absence of the treatment plan and admitted that the request for authorization was only sent after the surveyor's inquiry.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive and individualized care plan for a resident, who was at high risk for falls due to a history of falling and a fracture of the right femur. The care plan, initiated in March 2022, included an intervention to place a padded floor mat on the left side of the resident's bed to prevent falls. However, during multiple observations by the surveyor on consecutive days, the padded floor mat was found standing against the wall opposite the foot of the bed, rather than being placed on the floor as required by the care plan. Interviews with facility staff, including a nurse, a certified nursing assistant (CNA), and a unit manager, confirmed that the padded floor mat was not in use as per the care plan. The CNA admitted to not placing the mat on the floor after putting the resident to bed, and the unit manager acknowledged that the staff had not followed the resident's fall care plan. This oversight indicates a failure to adhere to the established care plan designed to meet the resident's needs and prevent falls.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that the pharmacy's monthly medication regimen review for a resident was reported to the attending physician and director of nursing and acted upon in a timely manner. The resident, who was admitted with diagnoses including Type 2 diabetes mellitus and chronic systolic heart failure, had their medications reviewed by a consultant pharmacist. On June 2, 2024, the pharmacist recommended decreasing the resident's potassium chloride dosage from 40 milliequivalents (meq) per day to 20 meq per day. However, this recommendation was not communicated effectively to the necessary parties, and the resident continued to receive the higher dosage. The Director of Nurses acknowledged during an interview that the facility missed the pharmacist's recommendation. A subsequent report from the consultant pharmacist on July 4, 2024, reiterated the recommendation to decrease the potassium dosage, noting that the resident's potassium blood level was 4.6, which suggested a reduction to 20 meq daily. Despite this, the recommendation status from the physician was listed as no response, and the resident continued to receive the higher dosage until the omission was discovered and corrected on July 12, 2024.
Discrepancy in Discharge Destination for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a discrepancy in the physician's order for the destination of discharge. The resident, who had been admitted with diagnoses including hypertension, heart failure, chronic kidney disease, and dementia, was supposed to be discharged to a local skilled nursing facility (SNF) closer to family, as requested by the healthcare proxy. Documentation indicated that the resident was to be transferred to Local SNF A, and this was confirmed by the social worker. However, the physician's order inaccurately stated that the resident was to be discharged to Local SNF B. During an interview, the Unit Manager acknowledged the error, attributing it to a transcription mistake while managing multiple discharges that week.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident, admitted in October 2018, the MDS assessments dated February, May, and August 2024 inaccurately reflected the admission date. Additionally, the resident developed a contracture, and the Occupational Therapy Discharge Summary indicated significant contractures in the resident's bilateral hands and wrists. However, the MDS assessments from May and August 2024 inaccurately reported no functional impairment in the resident's upper extremities. MDS Nurse #1 acknowledged the incorrect admission date, and MDS Nurse #2 admitted to not being aware of the contracture, leading to inaccurate MDS documentation. Another resident, admitted in July 2024 with multiple diagnoses, was discharged to a skilled nursing facility as per a physician's order and family request. However, the Discharge MDS assessment inaccurately indicated that the resident was discharged to an acute care hospital. MDS Nurse #2 confirmed the discharge status was incorrectly coded, which should have reflected the transfer to a skilled nursing facility.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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