Regalcare At Lowell
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 30 Princeton Boulevard, Lowell, Massachusetts 01851
- CMS Provider Number
- 225511
- Inspections on file
- 18
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Regalcare At Lowell during CMS and state inspections, most recent first.
The facility did not follow its abuse screening policy requiring a Massachusetts Nurse Aide Registry check for all employees prior to hire when a contracted occupational therapist was employed without documentation of this background check. Review of the personnel file showed no evidence that the registry check was completed before the therapist’s start date, and the DON confirmed during interview that the contracted staff member had not been screened through the Nurse Aide Registry as required by facility policy and contract.
A resident with a history of depression, suicidal ideation, PTSD, and bipolar disorder expressed suicidal thoughts and was hospitalized for evaluation. Upon return, the facility did not update the care plan, initiate recommended talk therapy, or document safety checks, despite available contracted services. The social worker was not notified, and the environment was not assessed for safety, allowing the resident to retain access to harmful substances. The resident later attempted suicide by ingesting nail polish remover, resulting in hospitalization.
Surveyors found extensive environmental deficiencies throughout both resident units, including stained ceiling tiles, damaged walls, broken blinds, missing closet doors, and ongoing plumbing issues. Interviews revealed that there was no specific plan to address these problems, and the maintenance department consisted of only one staff member who was unable to keep up with repairs or provide documentation of regular room rounds. These conditions failed to meet the facility's policy for maintaining a safe, clean, and homelike environment.
The facility did not provide scheduled or individualized activities for residents on two units, with multiple residents left unengaged in dining rooms despite posted activity calendars. A resident with cognitive impairment and limited English proficiency was not offered activities in their preferred language, and staff did not complete an activity assessment or implement care plan interventions. Staff and resident interviews confirmed a lack of activities, especially for those with dementia or language barriers.
The facility did not maintain a current CLIA certificate for the laboratory testing performed. An expired certificate was posted, and although payment for renewal was made, the application was incomplete and not followed up on until the survey. The Administrator confirmed the lapse and acknowledged the failure to complete the renewal process.
The facility did not consistently prepare or serve meals according to the IDDSI 6 (soft and bite-sized) therapeutic diet requirements as ordered by physicians. Multiple residents received food items that did not meet the required texture or size, such as large pieces of meat, potatoes with skin, and firm vegetables, making it difficult or impossible for some to eat. Staff interviews confirmed that the dietary staff did not follow the therapeutic diet manual for these residents.
A resident with impaired cognition and limited English proficiency was not communicated with in their primary language, Cantonese, by staff. Despite a care plan outlining the need for communication aids and interpreter services, staff consistently interacted with the resident only in English and did not use communication boards or language lines. Interviews confirmed staff were unaware of or did not utilize available communication resources, resulting in a lack of dignified and effective communication.
A resident with impaired mobility and cognition was observed multiple times with the call light out of reach, despite staff expectations that the call light should always be accessible.
A resident with impaired cognition and Cantonese as a primary language did not receive care in accordance with their communication care plan. Staff were observed interacting only in English, did not use communication boards or interpreter services, and were unaware of the resident's language needs. The resident engaged only with a family member in Cantonese, highlighting the facility's failure to implement the required communication interventions.
A resident with multiple comorbidities and high risk for skin breakdown developed a wound on the right elbow that was not identified or documented during routine skin assessments. Despite regular skin checks and a care plan addressing skin integrity, staff failed to record or report the wound, and no treatment orders were in place. The issue was only discovered during a surveyor's observation, with staff and providers unaware of the wound prior to this.
A resident with a suprapubic catheter was found to have a 16 French 5 cc balloon catheter in place, despite physician orders specifying a 14 French 10 cc balloon catheter. Nursing documentation indicated the catheter was changed as ordered, but observations and staff interviews confirmed the wrong size was used, resulting in a failure to follow professional standards of practice.
A resident with a history of depression and suicidal ideation verbalized thoughts of self-harm and later attempted suicide by ingesting nail polish remover. Despite facility policy and recommendations for immediate behavioral health intervention, there was no documentation of timely talk therapy or social work services, and staff were not promptly notified or involved. The resident's environment was not adequately assessed for safety, contributing to the deficiency.
A resident with a history of depression and suicidal ideation expressed SI and was hospitalized, but upon return, did not receive timely behavioral health or social services interventions such as talk therapy. Facility staff, including the social worker and contracted psych social worker, were not promptly notified, resulting in a lack of documented psychosocial support despite facility policy requiring such actions.
A resident with multiple medical conditions and documented food dislikes repeatedly received meals containing unwanted items, despite being cognitively intact and having clear preferences noted. Staff did not consistently follow the resident's dietary preferences, and both the Food Service Director and Dietitian were aware of the ongoing concerns. The facility's policy to accommodate resident choices and inspect meal trays was not effectively implemented.
A resident with a history of suicidal ideation did not receive recommended behavioral health interventions, including talk therapy, after returning from a hospital stay. The resident later attempted suicide by ingesting nail polish remover and was hospitalized. Despite this adverse event, facility leadership confirmed that no QAPI project was initiated to address the incident, in violation of QAPI requirements.
A room on a nursing unit was found unsecured and accessible, with a removed radiator cover and exposed electric radiator parts and wires on the floor. Staff confirmed that residents with dementia and wandering behaviors live on the unit, and that the room was not safe for them to enter.
Failure to Complete Required Nurse Aide Registry Check for Contract Occupational Therapist
Penalty
Summary
The facility failed to follow its Abuse Screening policy, dated March 2022, which required that all potential employees be screened to rule out a history of abuse, neglect, or mistreatment, including checking appropriate licensing registries and specifically checking the Nurse Aide Registry prior to employment for all facility employees. Record review showed that an occupational therapist was hired on 05/20/24, but her personnel file did not contain documentation that a Massachusetts Nurse Aide Registry background check had been completed before hire. During a telephone interview on 02/09/26, the DON stated that this occupational therapist was a contracted employee and acknowledged that a Massachusetts Nurse Aide Registry background check had not been conducted per the facility contract prior to hire, despite the facility’s policy that all employees, regardless of position, must have this check completed before employment. This deficiency centers on the facility’s inaction in obtaining and documenting the required Nurse Aide Registry background check for the occupational therapist prior to her start date, contrary to its written abuse prohibition and screening procedures.
Failure to Provide Appropriate Behavioral Health Services Following Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a known history of depression, suicidal ideation, PTSD, and bipolar disorder. The resident had previously vocalized suicidal ideation to staff, which resulted in a transfer to the hospital for evaluation. Upon return to the facility, there was no evidence that the care plan was reviewed, updated, or implemented to address the resident's ongoing mental health needs. Additionally, there was no documentation of 20-minute checks being initiated or a physician's order for such monitoring, despite the resident's recent expression of suicidal thoughts. The medical record did not indicate that a referral for talk therapy services was made, nor that the resident received talk therapy from psychiatric or social services, even though the hospital's psychiatric evaluation recommended this intervention and the facility had contracted services available. The social worker was not notified of the resident's suicidal ideation or hospital assessment, and did not assess or speak with the resident upon return. The care plan was not updated by the interdisciplinary team following the resident's statement of suicidal ideation, and the environment was not assessed for safety, as the resident later reported having access to nail polish remover since admission. Subsequently, the resident attempted suicide by ingesting nail polish remover, which resulted in hospitalization for acute medical complications. Interviews with facility staff, including the social worker, psychiatric nurse practitioner, and DON, confirmed that expected procedures—such as updating the care plan, initiating behavioral health services, and ensuring a safe environment—were not followed after the resident's expression of suicidal ideation and return from the hospital. The lack of timely and coordinated interventions contributed to the resident's continued decline and eventual suicide attempt.
Widespread Environmental Deficiencies Compromise Homelike Setting
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by widespread environmental deficiencies observed on both resident units. Surveyors documented numerous issues in resident rooms, including stained and damaged ceiling tiles, holes and gouges in walls, peeling wallpaper and paint, rusted radiators, missing or broken closet doors, broken blinds, and stained or damaged privacy curtains. Additional problems included continuously running toilets, loose or leaking faucets, missing thresholds, and areas where repairs had been started but not completed, such as patched but unpainted walls. Common areas, such as hallways and dining rooms, also exhibited damage, including stained ceiling tiles, gouged wall corners, and peeling wallpaper borders. Interviews with facility staff revealed that there was no specific plan in place to address these environmental deficiencies beyond ongoing maintenance. The Administrator confirmed the lack of a targeted plan, while the Director of Maintenance reported being the sole member of the maintenance department and expressed difficulty keeping up with the volume of needed repairs. The Director of Maintenance also stated that room rounds were supposed to be completed monthly, but was unable to provide documentation to support that these rounds had actually been conducted. The facility's own policy requires the provision of a safe, clean, comfortable, and homelike environment, but the observed conditions and staff interviews indicate that this standard was not being met. The deficiencies were present throughout both resident units and affected multiple aspects of the living environment, directly contradicting the facility's stated policy and the expectations for resident accommodations.
Failure to Provide Activities Program for All Residents, Including Those with Cognitive and Language Barriers
Penalty
Summary
The facility failed to provide a comprehensive activities program for residents on both observed units, as well as for a specific resident with cognitive and language barriers. Observations over several days revealed that scheduled activities listed on the facility's activity calendar were not conducted as planned. Residents were frequently seen sitting in dining rooms with the television on, but not engaged in any meaningful activities. Some residents were sleeping or staring into space, and there was a lack of individualized or group activities, particularly for those with dementia. Staff interviews confirmed that activities were not consistently provided, and there had been no activities director for several months, resulting in a reduction of available activities and inaccurate activity calendars. A resident with hemiplegia, hemiparesis, and moderately impaired cognition, who primarily speaks Cantonese and is rarely understood by staff, was observed repeatedly sitting alone in the dining room during scheduled activity times. The resident did not participate in any activities, and staff did not attempt to communicate in the resident's language or provide culturally or linguistically appropriate activities. The resident's care plan included general interventions such as introducing the resident to others and inviting them to activities, but these were not implemented. Staff acknowledged the language barrier and lack of engagement, and the resident's activity assessment was not completed. Resident and staff interviews further corroborated the lack of activities, especially for residents with dementia and those with language barriers. Residents reported that the posted activity calendar was not accurate and that activities were sparse or nonexistent for those with cognitive impairment. Documentation showed limited engagement for the resident with language needs, and facility leadership confirmed that activity assessments and care plans specific to individual needs, including language, were not completed or followed.
Failure to Maintain Current CLIA Certificate for Laboratory Testing
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of laboratory testing performed. A surveyor observed an expired CLIA certificate posted near the Administrator's office and, upon request, was provided documentation showing the certificate had expired. Although payment for a CLIA renewal application was made, the application was incomplete and not followed up on until the day of the survey. The Administrator confirmed that the facility conducts testing requiring a CLIA certificate and acknowledged that the renewal process was started but not completed due to lack of follow-up on required documentation.
Failure to Prepare and Serve IDDSI 6 Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that meals for residents prescribed an IDDSI 6 (soft and bite-sized) therapeutic diet were prepared and served according to the physician's orders and the facility's therapeutic diet manual. Observations over several days revealed that residents on the IDDSI 6 diet were served food items that did not meet the required texture and size specifications. For example, pork was served in cubes larger than 1/2 inch and not diced, potatoes were served with skin and not in a mashable form, and mixed vegetables included whole beans and carrots that were not appropriately prepared for the IDDSI 6 diet. Additionally, chicken pot pie and broccoli were served in forms not compliant with the soft and bite-sized requirements, with chicken pieces being too large and broccoli too firm and un-mashable. Au gratin potatoes were also served in large, crispy slices rather than mashable cubes without skin as required for the IDDSI 6 diet. Multiple residents with physician-ordered IDDSI 6 diets were observed struggling to eat their meals due to improper food preparation. One edentulous resident was unable to eat the meal provided, and two other residents reported that the broccoli was too hard to eat. The food service staff prepared and served the same food items to both IDDSI 7 (regular texture) and IDDSI 6 (soft and bite-sized) residents, disregarding the specific requirements for the therapeutic diet. Staff interviews confirmed that the dietary staff did not consistently follow the therapeutic diet breakdowns outlined in the facility's diet manual for the IDDSI 6 diets. The dietitian, Food Service Director, and Administrator all acknowledged during interviews that the dietary staff did not adhere to the prescribed meal textures for the IDDSI 6 diets. The facility had 13 residents with physician-ordered IDDSI 6 diets during the period in question, and the failure to follow the therapeutic diet manual was confirmed by both direct observation and staff interviews.
Failure to Communicate with Non-English Speaking Resident in a Dignified Manner
Penalty
Summary
Staff failed to treat a resident with dignity and did not effectively communicate in a language the resident understood. The resident, who was admitted with diagnoses including weakness and hemiplegia following a cerebral infarction, was assessed as having moderately impaired cognition and primarily spoke Cantonese. The resident's care plan identified impaired communication due to language barriers and included interventions such as using communication devices, allowing time to process information, and utilizing communication boards or interpreter services as needed. During multiple observations, staff were seen interacting with the resident only in English, which the resident did not understand, and did not attempt to use communication boards or interpreter services. Staff delivered meals, provided care, and assisted with toileting without engaging the resident in a language they understood or using alternative communication methods. The resident was observed to engage and communicate in Cantonese with a family member, but not with staff. Interviews with staff revealed a lack of awareness or use of communication aids, with several staff members stating they did not know the resident's primary language or how to communicate with them. Some staff mentioned that a kitchen staff member could help translate or that a language line was available, but none reported actually using these resources. The Director of Nursing confirmed that translation services and communication boards should be used, but acknowledged that staff were not following the communication care plan.
Call Light Not Accessible to Resident with Impaired Mobility and Cognition
Penalty
Summary
A deficiency was identified when a resident with a history of weakness, hemiplegia, and hemiparesis following a cerebral infarction was repeatedly observed in bed with the call light out of reach, located behind the bed on the floor. The resident, who speaks Cantonese and has moderately impaired cognition as assessed by staff, was unable to access the call light during multiple observations. Interviews with staff confirmed that the resident is expected to use the call light and that it should be accessible at all times, but on these occasions, it was not within the resident's reach.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement the communication care plan for a resident with moderately impaired cognition who primarily speaks Cantonese. Despite the care plan specifying the use of communication devices such as a communication board, allowing time to process information, anticipating needs, and assessing body and facial expressions, staff were repeatedly observed not following these interventions. Throughout multiple observations, staff interacted with the resident only in English, did not attempt to use communication aids, and did not utilize interpreter services. The resident did not engage or acknowledge staff communication attempts in English, but was observed communicating effectively in Cantonese with a family member. Interviews with staff revealed a lack of awareness regarding the resident's primary language and uncertainty about how to communicate when the family was not present. The CNA stated she did not know what language the resident spoke and relied on the family for communication. The Unit Manager and DON both acknowledged that staff should follow the care plan and use communication boards or interpreter services, but these were not observed in practice. The deficiency was identified through direct observation, interviews, and record review, demonstrating a failure to meet the resident's communication needs as outlined in the care plan.
Failure to Identify and Document Skin Wound on Resident's Elbow
Penalty
Summary
A deficiency occurred when the facility failed to identify and document a skin wound on a resident's right elbow during routine skin assessments. The resident, who had multiple diagnoses including sepsis, chronic ulcer of the lower leg, peripheral vascular disease, and kidney failure, was at high risk for skin breakdown and required substantial assistance with activities of daily living. Despite weekly skin checks and a care plan that included monitoring for skin issues, the wound on the right elbow was not recorded in the resident's medical record or skin assessments. Observations by surveyors revealed a scabbed, swollen area on the right elbow, which the resident reported as occasionally painful and known to staff. Review of the resident's medical record showed that only wounds on the shins were documented, and there was no mention of the right elbow wound in progress notes or skin assessments. Staff interviews confirmed that the area had not been previously identified or reported, and no treatment orders were in place for the elbow wound. The nurse practitioner and unit manager were unaware of the wound, and the DON acknowledged that the area should have been documented and assessed. No new skin assessment or treatment orders were found in the record following the surveyor's observation.
Failure to Follow Physician's Orders for Suprapubic Catheter Care
Penalty
Summary
Nursing staff failed to follow physician's orders regarding suprapubic catheter care for one resident with a history of urethral fistula, urinary retention, and neuromuscular dysfunction of the bladder. The resident's care plan and physician's orders specified the use of a 14 French catheter with a 10 cc balloon, to be changed every 30 days and as needed for blockage. However, observations revealed that the resident had a 16 French 5 cc balloon suprapubic catheter in place, which did not match the physician's order. Interviews with nursing staff and the Infection Control Nurse confirmed that the catheter size in use was not consistent with the physician's order. The Director of Nursing acknowledged that the catheter should have been implemented according to the order. Documentation in the Treatment Administration Record indicated that the catheter was changed as ordered, but direct observation and staff interviews contradicted this, showing a failure to adhere to professional standards of practice for catheter care.
Failure to Provide Timely Behavioral Health Services After Suicidal Ideation and Attempt
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of major depressive disorder, suicidal ideation, PTSD, and bipolar disorder. The resident verbalized suicidal ideation and subsequently attempted suicide by ingesting nail polish remover, which resulted in hospitalization. Prior to the attempt, the resident experienced increasing depression, social isolation, and lack of engagement, as noted by both the resident and staff. The facility's own policies required prompt identification, documentation, and intervention for changes in mental status and behavior, including immediate safety strategies and individualized care planning. Despite these requirements, the medical record did not show evidence that behavioral health services, such as talk therapy or social work intervention, were provided to the resident following the initial verbalization of suicidal ideation or after return from the hospital. The psychiatric consultant recommended talk therapy, and the hospital discharge plan also indicated the need for such services, but there was no documentation of a referral or provision of these services. Additionally, the social worker and contracted psychiatric social worker were not notified in a timely manner about the resident's suicidal ideation, resulting in a lack of immediate psychosocial support. Staff interviews revealed gaps in communication and awareness regarding the resident's mental health status and the suicide attempt. The CNA caring for the resident on the day of the attempt was not informed of the incident until after it occurred, and the nurse on duty did not recall any social work involvement at the time. The social worker stated she was not notified of the incident and therefore did not see the resident. The psychiatric nurse practitioner and DON both indicated that behavioral health services should have been initiated immediately, and the environment should have been assessed for safety, but these actions were not documented. The resident reported having access to the means for self-harm (nail polish remover) since admission, further indicating a lack of environmental safety assessment.
Failure to Provide Timely Social Services After Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to a resident who verbalized suicidal ideation (SI). The resident, with a history of major depressive disorder, prior suicidal ideation, PTSD, and bipolar disorder, expressed feelings of depression, loneliness, and a lack of support. The care plan included interventions such as providing a safe environment, encouraging open discussion of feelings, and periodic check-ins by social services. Despite these interventions, after the resident verbalized SI and was transferred to the hospital for evaluation, there was no documentation that social services or behavioral health services provided talk therapy or support upon the resident's return. Interviews with facility staff revealed gaps in communication and follow-up. The social worker, present in the facility after the resident's hospital assessment for SI, was not notified of the incident and did not see or speak with the resident. The contracted psych social worker, responsible for providing individual psychotherapy, was not informed of the resident's SI until seven days after the initial verbalization, by which time the resident had already been hospitalized for a suicide attempt. The psych nurse practitioner confirmed that only medication management was provided and that talk therapy should have been initiated immediately following the SI incident. The medical record review confirmed the absence of documented behavioral health or social services interventions, such as talk therapy, after the resident's expression of SI. The facility's own policies required staff to inform all involved personnel of suicide threats, monitor the resident's mood and behavior, and update care plans accordingly. However, these steps were not followed, resulting in a lack of timely psychosocial support for the resident after a critical mental health event.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
The facility failed to consistently honor a resident's food preferences, as evidenced by multiple observations, interviews, and record reviews. The resident, who was admitted with diagnoses including morbid obesity, heart failure, pemphigoid, and fibromyalgia, was found to be cognitively intact. Despite documented dislikes for certain foods such as corn, peas, and wax beans, the resident repeatedly received meals containing these items. The resident reported ongoing issues with receiving incorrect meals and expressed frustration over the lack of available options and the inability to directly contact the kitchen due to the absence of a phone in the room. Surveyors observed that staff, including those serving meals and the Activities Assistant, did not consistently follow the resident's documented food preferences, resulting in the resident being served unwanted foods. Both the Food Service Director and the Dietitian acknowledged awareness of the resident's ongoing concerns and agreed that staff should be honoring the resident's preferences. The facility's policy requires reasonable efforts to accommodate resident choices and for staff to inspect trays to ensure accuracy, but these procedures were not effectively implemented for this resident.
Failure to Implement QAPI Following Resident Suicide Attempt
Penalty
Summary
The facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that adequately addressed concerns related to behavioral health and medically related social services. Specifically, the facility did not ensure that its QAPI plan was implemented to address the needs of a resident with a known history of suicidal ideation. After the resident expressed suicidal thoughts and was transferred to the hospital for evaluation, the hospital recommended talk therapy. Upon the resident's return, there was no documentation that social services or psychiatric services, including talk therapy, were provided or that a referral was made as recommended. Subsequently, the same resident attempted suicide by ingesting nail polish remover and required hospitalization. Despite this adverse event, interviews with the Nursing Home Administrator and Director of Nursing revealed that no QAPI project was initiated in response to the suicide attempt, even though they acknowledged that such an event should be considered an adverse event for QAPI analysis. The facility's failure to analyze and address this incident through its QAPI process contributed to the deficiency.
Unsecured Room with Exposed Electrical Components
Penalty
Summary
The facility failed to provide a safe environment on one of two nursing units, as observed in an unoccupied resident room that was not secured and was accessible to both residents and staff. In this room, the radiator cover had been removed, and electric radiator parts and motors were spread out on the floor, exposing electric wires within the radiator. Facility policy requires a safe, clean, comfortable, and homelike environment. Interviews with nursing staff confirmed that residents with dementia and wandering behaviors reside on the unit, and that the unsecured room would not be safe for them to enter.
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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