Regalcare At Holyoke
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 282 Cabot Street, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225232
- Inspections on file
- 30
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Regalcare At Holyoke during CMS and state inspections, most recent first.
Surveyors identified that several MDS assessments were inaccurately coded, including cases where a resident receiving daily insulin was not coded for insulin administration, a pressure ulcer present on admission was not documented as such, and a resident on continuous oxygen therapy was not coded for oxygen use. Additional errors included incorrect documentation of anticoagulant use and discharge location, with staff interviews confirming these discrepancies between clinical records and MDS entries.
A resident with a history of brain tumor, Parkinson's Disease, epilepsy, and Tardive Dyskinesia experienced significant medication errors when Ingrezza (Valbenazine Tosylate) was not administered as prescribed on ten occasions. The MAR showed missed or unrecorded doses, accidental discontinuation of the medication order, and lack of documentation or provider notification regarding the missed doses. Nursing staff and the provider were unclear about the medication's order status, and the DON confirmed the errors and gaps in administration.
A required quarterly MDS assessment was not completed for a resident, as confirmed by record review and staff interview. The resident's clinical record showed only one MDS assessment submitted, with no subsequent quarterly assessment within the mandated timeframe, resulting in a failure to monitor the resident's status between comprehensive assessments.
A resident with a diagnosis of Schizoaffective Disorder and a history of alcohol use was admitted without a properly completed PASRR, as the screening was done after admission and failed to document the serious mental illness. Staff interviews confirmed ongoing issues with PASRR accuracy and timeliness, and the Ombudsman noted that mental health diagnoses were often missing from PASRRs during Medicaid screenings.
A resident with complex neurological conditions did not receive prescribed doses of Ingrezza for tardive dyskinesia on multiple occasions, with missed administrations not properly documented or communicated to the provider. Facility staff also discontinued and administered the medication without a current physician order, and the nurse practitioner was not made aware of the extent of missed doses, resulting in a failure to meet professional standards of medication administration.
A resident with paraplegia and other significant conditions experienced an unwitnessed fall and was found on the floor with the call bell out of reach. Staff failed to ensure the call bell was accessible after assisting the resident back to bed, and required fall mats were not in place as outlined in the care plan, as they had been removed for cleaning and not returned.
A resident receiving dialysis did not receive scheduled morning medications, including a phosphate binder meant to be given with meals, at the appropriate times on dialysis days. Medications were delayed until after the resident returned from dialysis, and the medication administration record inaccurately reflected the scheduled times. Facility staff did not coordinate medication administration with the dialysis schedule, resulting in missed and delayed doses.
Surveyors identified that the facility did not maintain accurate medical records for two residents. One resident's MAR showed morning medications as administered at scheduled times, even though the resident was away at dialysis and actually received the medications later in the day. Another resident with a Stage 3 pressure ulcer had multiple skin assessments and nursing evaluations incorrectly documented as having intact skin, despite ongoing treatment for the wound. These actions were inconsistent with facility policies and led to deficiencies in recordkeeping.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures—one with foot wounds and a recent amputation, and another with an indwelling urinary catheter. In both cases, staff provided high-contact care while wearing only gloves and a surgical mask, omitting the required gown, despite EBP signage and available PPE supplies.
The facility did not complete or transmit required MDS Discharge Assessments and Death in Facility Tracking Records for a resident discharged after treatment for sepsis and two residents who died in the facility. The MDS Nurse confirmed these records were not completed as required, despite referencing the RAI Manual for guidance.
A resident alleged physical abuse by a CNA, resulting in severe pain. The facility submitted an initial report to the DPH but delayed nearly four months in providing the final investigation results, despite multiple requests from the DPH. The DON, not present during the investigation, could not explain the delay.
The facility failed to maintain sufficient nursing staff, leading to delayed care for residents across three units. Staffing ratios often exceeded recommended levels, resulting in incidents where residents waited excessively for assistance. Interviews with staff highlighted frequent understaffing, call-outs, and a lack of contingency planning, contributing to unmet resident needs.
The facility failed to implement its smoking policy and ensure fire safety measures, as two residents were found with smoking materials despite requiring supervision. One resident with dementia kept cigarettes in a bag, while another with COPD and dementia smoked without a required apron. Staff interviews revealed a lack of a system to secure smoking materials and absence of fire safety equipment, contributing to the deficiency.
The facility failed to ensure a safe smoking environment by not having fire prevention equipment in the smoking area and not implementing smoking care plans for residents. Staff were untrained in smoking safety, leading to residents keeping smoking materials against policy and lacking necessary safety gear like smoking aprons.
The facility failed to serve palatable food at appropriate temperatures across three units and the main dining room. Residents reported cold and bland food, and test trays showed temperatures below acceptable levels. The use of Styrofoam trays due to a kitchen boiler issue and inefficient meal cart utilization contributed to the deficiency. Staff lacked awareness of proper serving temperatures.
The facility failed to maintain cleanliness in Unit #3 and Unit #4 kitchenettes, with toasters laden with crumbs and burnt material, posing a fire risk. A frozen item in Unit #3 was improperly labeled, lacking a resident's name and date, contrary to policy. Staff were uncertain about cleaning responsibilities, and the FSD acknowledged the lapses in daily cleaning and labeling procedures.
The facility failed to provide adequate care due to a lack of essential supplies like incontinence briefs, soap, and towels. Residents and staff reported frequent shortages, leading to inadequate care and the need for residents to purchase their own supplies. CNAs often brought personal items to meet residents' needs, and the administration was not fully aware of the extent of the shortages. The facility's supply management process lacked structure, contributing to the ongoing issue.
A resident with Parkinson's disease and moderate cognitive impairment reported a missing electric razor, but the facility failed to assist in filing a grievance or investigate the issue as per their policy. The social worker was unaware of the incident until informed by a surveyor, and no grievance form or investigation was documented.
A resident reported verbal abuse and threats by a CNA, but the facility failed to investigate or document the allegations as per policy. Additionally, a CNA was hired without required background checks, violating employee screening procedures.
A resident reported verbal abuse and threats from a CNA, but the LTC facility failed to protect the resident during the investigation. Despite the facility's policy to prevent further abuse, the resident continued to encounter the CNA, and no immediate protective measures or interviews were conducted. The facility did not document attempts to interview the resident or other witnesses promptly, leaving the resident feeling unsafe.
A facility failed to provide a resident with recommended psychotherapy services as identified by the PASRR Level II Evaluation. Despite the resident's willingness to receive therapy, there was no documentation of the service being provided. A social worker confirmed the oversight, highlighting a lapse in the facility's process to ensure necessary mental health services were delivered.
A resident with a transmetatarsal amputation and other medical conditions was not provided with a recommended protective boot, despite multiple observations by surveyors. The facility failed to act on the Wound PA's recommendation to obtain a Darco boot, which was intended to protect the surgical area. Interviews revealed a lack of communication between nursing and rehabilitation departments, resulting in the resident only receiving daily bandaging.
A resident did not receive necessary vision care services despite requesting them and being assured by the facility of contracted services. The resident, who was cognitively intact, reported not receiving new glasses after an eye doctor visit, and the facility failed to follow up on the resident's vision care needs. Interviews revealed a lack of documentation and coordination among staff, leading to the deficiency.
A resident with ESRD did not receive scheduled medications on dialysis days due to a lack of coordination between the facility and the dialysis center. The facility's policy required staff to be trained in medication timing for dialysis patients, but this was not followed. The resident missed doses of Gabapentin, Acetaminophen, Hydralazine, and Vistaril because the medications were not sent to the dialysis center, and the administration times were not adjusted.
The facility failed to conduct annual performance appraisals for two CNAs, as required. The Facility Assessment lacked documentation on the need for these appraisals, and interviews confirmed that the appraisals should have been conducted annually by the DON or Unit Manager. The facility also did not have a policy for performance appraisals, which contributed to this deficiency.
A resident with Parkinson's disease and depression did not receive necessary Behavioral Health Services despite having consent on file. The resident showed symptoms of depression, and concerns were raised by family members. However, the referral process was not completed, and the resident's name was not recorded in the Behavioral Health book, resulting in a lack of service provision.
A resident with GERD and dysphagia did not receive necessary speech therapy services for swallowing difficulties, despite a physician's order and recommendations from a dietician and NP. The facility's referral process failed, as the Director of Rehabilitation found no evidence of a referral, and the resident was not seen by an SLP, increasing the risk of adverse effects.
The facility failed to accurately code MDS Assessments for three residents, leading to discrepancies in their medical records. One resident was incorrectly documented as receiving anticoagulant medication, while another was inaccurately noted as using a pressure relieving mattress and a limb restraint. These errors were confirmed by the MDS Nurse, highlighting the need for corrections.
Inaccurate MDS Coding for Medications, Treatments, and Discharge Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) Assessments for six residents, resulting in multiple discrepancies between clinical documentation and MDS entries. For example, one resident with a history of diabetes was administered insulin daily as ordered by the physician, but the MDS assessment did not reflect any insulin administration or injections during the observation period. Another resident with a longstanding callous that developed into a pressure ulcer upon admission was not coded as having a pressure injury present on admission, despite clinical notes and wound care documentation indicating otherwise. Additional inaccuracies included a resident who was coded as receiving an anticoagulant during the MDS lookback period, although there were no physician orders or medication administration records supporting this. Another resident, who was observed and ordered to receive continuous oxygen therapy, was incorrectly coded as not utilizing oxygen on the MDS assessment. Furthermore, a resident with a documented stage 3 pressure area during the observation period was not coded for any pressure injuries on the MDS, despite ongoing wound care treatments documented in the clinical record. Finally, a discharge MDS assessment was completed for a resident indicating discharge to an acute hospital, while clinical progress notes confirmed the resident was actually discharged home. These coding errors were confirmed through interviews with the MDS nurse and other clinical staff, who acknowledged the inaccuracies in the MDS assessments compared to the residents' clinical records and care provided.
Failure to Ensure Resident Was Free from Significant Medication Errors
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors related to the administration of Ingrezza (Valbenazine Tosylate), a medication prescribed for Tardive Dyskinesia (TD). The resident, who had a complex medical history including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls, was admitted in June 2024. The provider's progress notes consistently indicated that Ingrezza 80 mg via G-tube at bedtime was to be continued for significant TD, as involuntary movements were likely contributing to the resident's falls and the medication appeared to be beneficial. Review of the Medication Administration Records (MAR) for May and June 2025 revealed that the resident missed a total of ten doses of Ingrezza out of 47 opportunities. Specific dates were identified where the medication was either not administered, not initialed as given, or marked as not given without documented reasons or correlating progress notes. Additionally, there was a period where the medication order was discontinued without clear justification, and the provider stated that they had not discontinued the medication since it was restarted in May 2025. The DON and Regional Nurse Consultant confirmed that several doses were missed, some due to the medication being accidentally discontinued and others for reasons that required further research. Interviews with nursing staff and the provider revealed a lack of clarity regarding the medication's administration and order status. The nurse was unaware of the discontinuation and believed the medication should have been continued at bedtime. The provider confirmed the intent to continue the medication, and the DON acknowledged missed doses and accidental discontinuation. There was no documentation indicating that the provider had been notified of the missed doses, nor was there evidence explaining why the medication was not administered on the identified dates.
Failure to Complete Required Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required quarterly Minimum Data Set (MDS) assessment for one resident, as mandated by federal regulations. Specifically, the resident was admitted in February 2023, and while an MDS assessment was submitted on 2/5/25, there was no evidence in the clinical record of any subsequent quarterly assessment being completed within the required 92-day timeframe. During an interview, the MDS Nurse confirmed that a quarterly assessment should have been completed in May 2025 but was not done, despite referencing the RAI Manual for assessment timeliness. This lapse resulted in the resident not being reviewed between comprehensive assessments, which is necessary to monitor critical indicators of gradual status change as specified in the quarterly assessment requirements.
Failure to Complete Accurate PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed prior to the admission of a resident with a diagnosis of Schizoaffective Disorder and a history of alcohol use. The resident was admitted with documented mental health diagnoses, and hospital records indicated recent changes to antipsychotic medication. Despite this, the PASRR was not completed until after admission and was inaccurately filled out, omitting the resident's serious mental illness diagnosis. Interviews with facility staff revealed that the social worker was aware of issues with both the timing and accuracy of PASRR completion, noting that no audit had been conducted to identify other residents with similar deficiencies. Additionally, the Ombudsman reported that PASRRs were frequently missing mental health diagnoses and other critical information during Medicaid screenings, further indicating a pattern of incomplete or inaccurate PASRR documentation.
Failure to Administer Prescribed Medication and Notify Provider
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for one resident by not administering the medication Ingrezza (Valbenazine Tosylate), prescribed for tardive dyskinesia, as ordered by the provider. The medication was missed on multiple occasions, as documented in the Medication Administration Record (MAR), with no evidence of administration or appropriate documentation for the missed doses. Additionally, there was a period when the medication was discontinued by facility staff and administered without a current physician order, contrary to the provider's intent and without proper communication or documentation. The resident involved had complex medical needs, including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls. The provider's progress notes indicated that the resident experienced increased involuntary movements and falls when the medication was not administered as prescribed. Despite these clinical changes, there was no documentation in the medical record explaining the missed doses or evidence that the provider was notified about the medication not being given on at least ten occasions. Interviews with nursing staff and the nurse practitioner revealed a lack of clarity regarding the medication orders and administration. The nurse practitioner stated that she had not discontinued the medication and was unaware of the extent of missed doses, indicating a breakdown in communication and failure to follow facility policy and professional standards regarding medication administration and provider notification.
Failure to Ensure Call Bell Accessibility and Fall Mat Implementation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for one resident with significant medical conditions, including paraplegia, spinal stenosis, muscle contractures, and blindness in one eye. The resident was found on the floor after an unwitnessed fall, with the call bell not activated and out of reach, partially under the bed. Staff interviews confirmed that the resident was capable of using the call bell, but it had not been placed within reach after staff assisted the resident back into bed following the fall. Three staff members exited the room without ensuring the call bell was accessible to the resident. Additionally, the resident's care plan, updated after the fall, required fall mats to be placed on both sides of the bed. However, during a subsequent observation, no fall mats were present, and staff confirmed that the intervention had not been implemented. The mats had been removed by housekeeping for cleaning and were not returned to the resident's room before the resident's return. These failures resulted in the environment not being free from accident hazards and lacking adequate supervision and interventions to prevent further accidents.
Failure to Provide Timely and Appropriate Dialysis-Related Medication Administration
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident receiving dialysis. Specifically, the facility did not ensure timely administration of scheduled morning medications on the resident's dialysis days. The resident, who was cognitively intact and had a diagnosis of chronic kidney disease, was transported to an outside dialysis clinic early in the morning and returned in the early afternoon. During this time, the resident received a bagged breakfast before leaving but did not have facility medications sent with them, resulting in morning medications being delayed until after their return from dialysis. Additionally, the facility did not administer Sevelamer, a phosphate binder prescribed to be given with meals, as ordered by the physician. The resident's blood phosphorus levels were elevated, and the Sevelamer dose intended for breakfast was consistently missed on dialysis days because it was not sent with the resident or administered at the appropriate time. The medication administration record inaccurately reflected that medications were given at the scheduled times, even though they were actually administered after the resident returned from dialysis. Interviews with nursing staff, the unit manager, the director of nursing, the registered dietitian, and the nurse practitioner confirmed that the medication administration times were not coordinated with the resident's dialysis schedule. The staff were unaware that the Sevelamer was not being administered with breakfast on dialysis days, and the provider was not informed of the delayed medication administration until after the issue was identified by the surveyor. Facility policies required medications to be administered in a timely manner and as prescribed, but these were not followed for this resident.
Failure to Maintain Accurate Medical Records for Medication Administration and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to medication administration documentation and skin assessment records. For one resident with chronic kidney disease who received dialysis three times a week, the facility did not accurately document the administration times of multiple morning medications. Although the resident left the facility early in the morning for dialysis and did not receive medications at the scheduled times, the Medication Administration Record (MAR) indicated that medications were administered at the prescribed morning times. Interviews with nursing staff confirmed that medications were actually given upon the resident's return in the afternoon, and that the MAR did not reflect the true administration times. Another resident, admitted with diagnoses including Type 2 Diabetes and severe cognitive impairment, had a Stage 3 pressure ulcer on the coccyx. Despite ongoing treatment and weekly wound consultant evaluations, the facility's Skin Observation Tools and Nursing Evaluation records inaccurately documented the resident's skin as intact on several dates after the pressure ulcer was first identified. The Assistant Director of Nursing acknowledged that these assessments were incorrect and that the pressure area should have been documented in the relevant records. These deficiencies were identified through observation, interviews, and record reviews, and were found to be inconsistent with the facility's own policies regarding medication administration and comprehensive assessments. The failures involved both the documentation of medication administration for a resident out of the facility for dialysis and the accurate recording of a pressure ulcer in skin assessments for another resident.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program on one unit by not adhering to Enhanced Barrier Precautions (EBP) for two residents with conditions requiring such measures. For one resident with a history of chronic foot ulcers, recent amputation, and surgical wounds, staff were observed providing direct care, including assisting with footwear and transfers, while only wearing gloves and a surgical mask, but not donning a gown as required by the facility's EBP policy. The EBP signage and PPE supplies were present, but the staff did not follow the full PPE protocol during high-contact care activities. Similarly, another resident with an indwelling urinary catheter was placed on EBP, but staff providing high-contact care, such as toileting and changing, were observed wearing only gloves and a surgical mask, omitting the required gown. The Assistant Director of Nursing confirmed that both residents were on EBP due to their medical conditions and that full PPE, including gowns, should have been used during care. These observations demonstrate a failure to consistently implement the facility's EBP policy for residents at increased risk of MDRO transmission.
Failure to Complete and Submit Required MDS and Death Tracking Records
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) Assessments and Death in Facility Tracking Records for multiple residents. For one resident admitted with sepsis and later discharged to the community, a Discharge MDS Assessment was not completed at the time of discharge. The MDS Nurse confirmed during an interview that this assessment should have been completed but was not. Additionally, two other residents who expired in the facility did not have Death in Facility Tracking Records completed as required. Review of their records showed that, despite documentation of their deaths in nursing progress notes and pronouncement forms, the necessary MDS tracking records were not completed or submitted. The MDS Nurse acknowledged in interviews that these records should have been completed for both residents but were not, despite referencing the RAI Manual for guidance on accuracy and timeliness.
Delayed Reporting of Abuse Investigation Results
Penalty
Summary
The facility failed to report the final results of an abuse investigation to the Department of Public Health (DPH) within the required five working days. The incident involved a resident who alleged physical abuse by a Certified Nurse Aide (CNA) during care, resulting in severe pain. The initial report was submitted to the DPH on June 6, 2024, following the resident's allegation that the CNA dropped their legs during care on June 5, 2024. Despite the initial report, the facility did not provide the final investigation results to the DPH until October 1, 2024, nearly four months later. The facility's policy, revised in March 2022, mandates that investigation results be reported to the administrator and relevant officials within five working days. However, the facility was repeatedly contacted by the DPH Intake Department on multiple occasions, including June 11, July 17, August 29, September 4, September 17, and September 20, 2024, requesting the final summary of the investigation. The Director of Nurses, who was not employed at the facility during the investigation, was unable to explain the delay in submitting the final report.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents across three units, as determined by their Facility Assessment. The staffing ratios on multiple occasions exceeded the recommended levels, particularly on Unit Two, Unit Three, and Unit Four. For instance, on Unit Two, the day shift staffing ratio exceeded the recommended 1:10 on one day, and the evening shift ratio was greater than 1:11 on six days. Similar issues were observed on Unit Three and Unit Four, with staffing ratios often exceeding the recommended levels, leading to inadequate care for residents. The deficiency was further highlighted by specific incidents involving residents. On Unit Four, a resident's call bell was not responded to for 18 minutes, during which the resident was found in a soiled state, indicating a lack of timely assistance. Another resident on Unit Three experienced an 82-minute wait for assistance with a simple task, such as plugging in a radio. These incidents underscore the impact of insufficient staffing on the residents' ability to receive timely and adequate care. Interviews with staff members revealed a consistent pattern of understaffing, with CNAs often working alone or with insufficient support, leading to delays in care and unmet resident needs. Staff expressed frustration over frequent call-outs and the lack of a contingency plan to address staffing shortages. The absence of a staffing coordinator and reliance on an outdated emergency staffing policy further exacerbated the situation, contributing to the facility's inability to maintain adequate staffing levels and ensure the well-being of its residents.
Failure to Implement Smoking Policy and Fire Safety Measures
Penalty
Summary
The facility failed to establish and implement a comprehensive smoking policy in accordance with applicable Federal, State, and local laws and regulations. The policy did not address preventative measures in the event of a fire emergency, such as the provision of fire prevention equipment in designated smoking areas. The facility's smoking policy, revised in March 2022, permitted smoking only in designated areas and required that residents without independent smoking privileges have their smoking materials stored securely. However, the policy lacked specific instructions on fire prevention equipment and measures. The facility did not adhere to its smoking policy concerning two residents, who were observed possessing smoking materials despite requiring supervision. One resident, admitted with dementia and moderate cognitive impairment, was observed keeping cigarettes in a zippered bag on their wheelchair, contrary to the policy that required smoking materials to be stored by the facility. Another resident, with diagnoses including COPD and dementia, was also found to have cigarettes in their possession and was observed smoking without a required smoking apron. Interviews with staff revealed inconsistencies in the implementation of the smoking policy. A CNA indicated that residents were not allowed to keep smoking materials due to safety concerns, yet residents were observed with such materials. Another CNA noted the absence of a system to secure smoking materials and the lack of fire safety equipment, such as smoking aprons, fire blankets, and extinguishers, in the smoking areas. This lack of adherence to the smoking policy and absence of fire safety measures contributed to the deficiency identified by the surveyors.
Deficiency in Smoking Safety Protocols
Penalty
Summary
The facility failed to ensure a safe smoking environment for residents by not having fire prevention equipment readily available in the designated smoking area. During observations, it was noted that there were no fire extinguishers or fire blankets present, and staff were not aware of what actions to take in case of a fire emergency. This lack of preparedness was confirmed by interviews with staff, including a CNA and the Regional Director of Operations, who acknowledged the absence of necessary fire prevention tools. Additionally, the facility did not implement the smoking plan of care for certain residents. Two residents were observed keeping smoking materials in their possession despite their care plans indicating that these materials should be stored by the facility. Furthermore, residents who were assessed to require smoking aprons for safety were not provided with them during smoking sessions. Interviews with staff revealed that smoking aprons were a new requirement and had not been available until recently, indicating a gap in the facility's adherence to safety protocols. The facility also failed to provide adequate education to staff regarding smoking safety and procedures. Several CNAs reported that they had not received any formal training on how to manage resident smoking safely. This lack of training left staff unprepared to handle potential emergencies, as evidenced by their uncertainty about what actions to take if a resident were to ignite themselves. The absence of a structured educational program contributed to the overall deficiency in ensuring a safe smoking environment for residents.
Deficiency in Serving Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve palatable food at an appetizing temperature to residents across three units and the main dining room. During a Resident Council Meeting, residents from Units Three and Four expressed concerns about the food being cold, bland, or overly salty. Observations on Unit Two revealed similar complaints about the food being consistently cold. On Unit Three, the surveyor noted that the meal tray pass was completed over a span of 23 minutes, and the test tray temperatures were below acceptable levels, with hamburger macaroni at 108°F, cooked carrots at 90°F, and milk at 52°F. The surveyor also noted inconsistent temperatures within the same dish, indicating improper heating or holding methods. In the main dining room, the Food Service Director acknowledged difficulties in maintaining food temperatures due to the use of Styrofoam trays, as the kitchen's boiler was down. On Unit Four, the surveyor observed that the meal carts were not efficiently utilized, leading to further delays in serving food. The test tray on this unit showed significantly low temperatures, with pureed pork at 82°F and mashed potatoes at 78°F. Interviews with staff revealed a lack of awareness regarding the appropriate serving temperatures for food, contributing to the deficiency in providing meals at a palatable temperature.
Deficiencies in Kitchenette Cleanliness and Food Labeling
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in two of its unit kitchenettes, specifically Unit #3 and Unit #4. Observations revealed that the toaster crumb drawers in both units were laden with crumbs and had burnt material inside, posing a potential fire risk. Additionally, a frozen item in the Unit #3 kitchenette freezer was found without a resident's name or a proper date, contrary to the facility's policy requiring perishable foods to be labeled with the resident's name and use-by date. Interviews with nursing staff indicated uncertainty about the responsibility and frequency of cleaning the kitchenettes. The Food Service Director (FSD) acknowledged that the kitchenettes should be cleaned daily, including the toasters, and expressed uncertainty about why the frozen item was improperly labeled. The FSD confirmed that items in the freezer should be dated to ensure they are discarded after three days. The lack of proper labeling and cleaning suggests a lapse in adherence to the facility's policies and procedures, contributing to the observed deficiencies.
Supply Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure that residents received appropriate care and services, as evidenced by a lack of essential supplies such as incontinence briefs, soap, towels, and washcloths. During a re-certification survey, residents and staff reported that these supplies were frequently unavailable, leading to inadequate care. Residents had to purchase their own supplies, and staff sometimes brought in personal items to meet the residents' needs. The shortage of supplies was a recurring issue, with staff indicating that they had to use incorrect sizes of incontinence briefs, which could potentially lead to skin breakdown. Interviews with Certified Nursing Assistants (CNAs) revealed that the shortage of supplies had been ongoing, with some CNAs resorting to hiding supplies to ensure they had enough for their residents. The CNAs reported that they had informed the administration about the shortages, but the supplies were still not consistently available. The Director of Laundry/Maintenance mentioned that supplies were delivered at specific times, but there were still instances when supplies were not available, and staff had to rely on sister facilities or purchase items from stores. The facility's administration was not fully aware of the extent of the supply shortages. The Administrator, who had only been in the position for 16 days, was not informed of the issues, and the Assistant Director of Nurses (ADON) acknowledged a recent delay in delivery but did not follow up with staff to confirm the availability of supplies. The ADON also mentioned that the facility was working on establishing appropriate levels for ordering supplies, indicating a lack of structure in the supply management process.
Failure to Implement Grievance Policy for Missing Item
Penalty
Summary
The facility failed to implement its grievance policy and assist a resident in filing a grievance regarding a missing electric razor. The resident, who was admitted with Parkinson's disease and had moderate cognitive impairment, was dependent on staff for personal hygiene. The resident's family reported the missing razor, with the charger still plugged into the wall, but the razor itself was not found. Despite this report, the facility staff did not follow up or investigate the missing item as required by their grievance policy. The facility's policy, dated August 2019, mandates that staff assist residents in filing grievances and that the Director of Social Services should begin an investigation upon receipt of a grievance. However, the social worker was unaware of the missing razor until informed by a surveyor and found no evidence of a grievance form or investigation in the grievance log. The process for handling missing items was not followed, and the resident was not reimbursed for the missing razor.
Failure to Implement Abuse Policies and Employee Screening Procedures
Penalty
Summary
The facility failed to implement its abuse policies and procedures, specifically in the case of Resident #30, who alleged verbal abuse by a Certified Nurse Aide (CNA). The resident, who was cognitively intact with a BIMS score of 14, reported multiple incidents involving the CNA, including being denied a request for ginger ale, being threatened with physical harm, and witnessing the CNA eating off residents' trays. Despite these allegations being reported to various staff members, including the head nurse and an activities assistant, there was no documentation of an investigation or follow-up in the resident's medical record. The Director of Nursing (DON) and Administrator were informed of the allegations, but the expected immediate interview and documentation process did not occur. Additionally, the facility failed to adhere to its employee screening procedures. CNA #4 was hired without evidence of a CORI check or Nurse Aide Registry check, which are required to ensure that new employees have no previous findings of abuse, neglect, or mistreatment. This oversight was confirmed during an interview with the Regional Consultant Nurse, who stated that the facility could not provide documentation of these checks for CNA #4. The facility's policies, dated March 2022, clearly outline the procedures for investigating abuse allegations and screening new employees. However, these procedures were not followed in the case of Resident #30 and CNA #4, leading to deficiencies in the facility's handling of abuse allegations and employee screening. The lack of immediate investigation and documentation, as well as the failure to conduct necessary background checks, highlight significant lapses in the facility's adherence to its own policies.
Failure to Protect Resident from Potential Abuse During Investigation
Penalty
Summary
The facility failed to prevent the potential for further abuse of a resident during an investigation of an abuse allegation. The resident, who was cognitively intact, reported multiple incidents involving a CNA, including verbal abuse and threatening behavior. Despite the resident's reports to various staff members, the facility did not take immediate action to protect the resident from further potential abuse. The facility's policy required that all alleged violations be thoroughly investigated and that measures be taken to prevent further potential abuse during the investigation. However, the resident continued to encounter the accused CNA during activities, and no immediate interviews or protective measures were implemented. The resident expressed feeling unsafe, and the facility did not document any attempts to interview the resident or other potential witnesses promptly. Interviews with facility staff revealed that the expected protocol for handling abuse allegations was not followed. The resident was not interviewed immediately, and there was no documented evidence of interviews with other residents, staff, or visitors. The facility's failure to identify and remove the accused CNA from the schedule left the resident exposed to further potential abuse, contrary to the facility's policies.
Failure to Provide Recommended Psychotherapy Services
Penalty
Summary
The facility failed to provide recommended specialized services for a resident with a serious mental illness (SMI) as identified by the Preadmission Screening and Resident Review (PASRR) Level II Evaluation. The resident, who was admitted in January 2024 with a diagnosis of Bipolar Disorder, was recommended to receive individual psychotherapy by the Department of Mental Health. Despite the resident's openness to psychotherapy as noted in a Behavioral Health Group note dated March 22, 2024, there was no documented evidence in the medical record that the resident received the recommended psychotherapy services. During an interview, a social worker confirmed the absence of documentation indicating that the resident had been seen for talk therapy since agreeing to the service. The social worker explained that the facility's process involves reviewing psych recommendations and placing them in a psych book on each unit for the therapist to follow up. However, the resident was not seen by a therapist as required by the PASRR Level II Evaluation recommendations, indicating a lapse in the facility's process to ensure the provision of necessary mental health services.
Failure to Implement Recommended Protective Boot for Resident
Penalty
Summary
The facility failed to implement a recommended intervention for a resident who had undergone a transmetatarsal amputation (TMA) and was diagnosed with Type 2 Diabetes Mellitus and osteomyelitis. The resident was observed multiple times without a protective boot, which had been recommended by the Wound Physician's Assistant (PA) to protect the surgical area and reduce weight-bearing pressure on the wound. Despite the recommendation made on April 26, 2024, the facility had not initiated the process to obtain the Darco boot by the time of the survey. Interviews with facility staff revealed a lack of communication and follow-through regarding the recommendation for the protective boot. Nurse #2 confirmed that the resident did not have the boot and was only receiving daily bandaging. The Regional Rehabilitation Director was unaware of the recommendation until informed by the surveyor, indicating a breakdown in communication between nursing and rehabilitation departments. The Wound PA expected the facility to have started the process to obtain the boot within a week of the recommendation, but this had not occurred.
Failure to Provide Vision Care Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident, who was cognitively intact, had requested eye care services from a mobile contracted agency upon admission. Despite this request, the resident reported not receiving new glasses after an eye doctor visit the previous year, which was supposed to address worsening vision. The resident's son also confirmed that the facility assured them of contracted vision services, yet no follow-up or provision of glasses occurred. Interviews with facility staff revealed a lack of documentation and follow-up regarding the resident's vision care needs. A nursing progress note indicated that the resident's son was informed about the need for new glasses, but no action was taken. The social worker confirmed the absence of documentation for the resident's vision concerns, and a nurse admitted that the referral information was not acted upon. The contracted eye doctor stated that he visits the facility monthly but only sees residents on a provided list, suggesting a breakdown in communication and coordination within the facility.
Failure to Coordinate Medication Administration with Dialysis Schedule
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident with End Stage Renal Disease (ESRD) who required dialysis. The deficiency involved the failure to coordinate the administration of medications with the resident's dialysis schedule. The facility's policy required staff to be trained in the timing and administration of medications for residents receiving dialysis, but this was not adhered to. The resident, who was admitted with a diagnosis of ESRD, received dialysis treatments three times a week at an off-site center. However, the Medication Administration Record (MAR) indicated that the resident did not receive several scheduled medications on dialysis days due to being absent from the building. The medications not administered included Gabapentin, Acetaminophen, Hydralazine, and Vistaril, which were scheduled for administration at specific times that coincided with the resident's dialysis sessions. Nurse #2, responsible for the resident's care, assumed that the medications were administered at the dialysis center, but later confirmed that the center did not provide these medications. The Director of Nurses acknowledged that the medications should not have been omitted and that the administration times should have been adjusted to ensure the resident received all prescribed medications as ordered by the physician.
Failure to Conduct Annual CNA Performance Appraisals
Penalty
Summary
The facility failed to ensure that annual performance appraisals for Certified Nurse Aides (CNAs) were completed every 12 months, as required. Specifically, two CNAs, identified as CNA #4 and CNA #5, did not have documented evidence of performance appraisals in their Human Resource records. The Facility Assessment, dated 4/17/24, also lacked documentation addressing the need for these appraisals. Interviews with the Infection Control Nurse/Staff Development Coordinator and the Regional Consultant Nurse confirmed that the appraisals should have been conducted annually and maintained in the employees' HR records. The deficiency was further highlighted during interviews, where it was revealed that the Director of Nursing or Unit Manager was responsible for completing these appraisals. However, the facility did not have a policy in place for conducting performance appraisals. The Administrator acknowledged the absence of such a policy, and the Regional Consultant Nurse noted that the new Administrator and Director of Nursing were not accountable for past practices. This lack of documentation and policy led to the failure in conducting the required annual performance appraisals for the CNAs.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary Behavioral Health care and services to a resident diagnosed with Parkinson's disease and depression. The resident, who was admitted in August 2023, showed symptoms of depression, including fatigue, sleep disturbances, and withdrawal. Despite having a consent form for Behavioral Health Services dated December 2023, there was no documented evidence that these services were provided. The resident's Minimum Data Set (MDS) Assessment indicated moderate cognitive impairment, and the resident was on antidepressant medication, Sertraline, since August 2023. Concerns about the resident's depression were raised by the Health Care Proxy and the resident's sister during a Care Plan Meeting in April 2024, with a recommendation for psychiatric services. However, the Social Worker acknowledged that the process for initiating Behavioral Health Services was not completed, as the resident's referral was not recorded in the Behavioral Health book used to track service initiation. Consequently, the resident did not receive the necessary Behavioral Health Services, despite having consent on file.
Failure to Provide Speech Therapy for Swallowing Difficulties
Penalty
Summary
The facility failed to provide specialized rehabilitation services for a resident who was experiencing ongoing difficulty swallowing, which increased the risk of adverse effects such as aspiration pneumonia or choking. The resident, who was admitted in June 2023, had diagnoses of GERD and dysphagia and was cognitively intact with a BIMS score of 14 out of 15. Despite a physician's order for speech therapy to evaluate and treat the resident's swallowing difficulties, there was no evidence that the resident was seen by a speech-language pathologist (SLP). The facility's assessment indicated that speech/language services would be provided based on the resident's needs, but this was not fulfilled. Interviews revealed that the referral process for speech therapy was not properly executed. The Director of Rehabilitation noted that no SLP notes were available for the resident and that the referral process involved completing a therapy communication form, which was not done. Nurse #3 confirmed that the resident continued to have swallowing concerns and that recommendations for SLP evaluation made by both the dietician and nurse practitioner in December 2023 were not communicated, resulting in the resident not being seen by the SLP. The nurse practitioner stated that she communicated new orders verbally and in writing, but the referral for the resident was not completed, indicating a breakdown in communication and process.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for three residents, leading to discrepancies in their medical records. Resident #9, admitted with a diagnosis of Vascular Dementia, was inaccurately coded as receiving anticoagulant medication within seven days of the assessment reference date, despite no documentation supporting this in the medical record. Similarly, Resident #56, with diagnoses including Parkinson's Disease and Hypertension, was also incorrectly coded as receiving anticoagulant medication, with no supporting documentation found in the resident's record. Resident #50, admitted with Dementia with Anxiety and a history of a wound to the coccyx, was observed using a pressure relieving mattress, which was not reflected in the MDS assessment. Additionally, the assessment inaccurately indicated the use of a limb restraint, which was never utilized according to the resident's medical record and staff interviews. These inaccuracies were confirmed by the MDS Nurse, who acknowledged the need for modifications to correct the errors in the assessments.
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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