Regalcare At Quincy
Inspection history, citations, penalties and survey trends for this long-term care facility in Quincy, Massachusetts.
- Location
- 211 Franklin Street, Quincy, Massachusetts 02169
- CMS Provider Number
- 225522
- Inspections on file
- 20
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regalcare At Quincy during CMS and state inspections, most recent first.
Four residents with cognitive and physical impairments were repeatedly observed with their call lights out of reach, either on the floor or draped over nightstands, making them unable to call for staff assistance. Staff interviews confirmed that call lights should have been accessible at all times, but this was not maintained according to facility policy.
The facility did not ensure residents were aware of or had access to the grievance process, as several residents reported not seeing postings or knowing how to file grievances except by telling staff. Grievance forms were not readily available on all units, and there was no clear method for anonymous submission, with the social worker confirming these deficiencies during a facility tour.
The facility did not develop or implement individualized care plans for several residents, including those with pain management needs, antipsychotic medication use, fall risk, and oxygen therapy. Care plans were incomplete, generic, or missing, and staff failed to document required assessments and interventions, resulting in deficiencies in meeting residents' specific care needs.
Two residents with severe cognitive impairment were exposed to accident hazards when a wound treatment cart containing medications was left unlocked and unattended in a common area, allowing one resident to rummage through its contents, and when a freestanding oxygen cylinder was repeatedly observed unsecured in a resident's room near the bed. Staff interviews confirmed that these practices did not follow facility policy or safety standards.
A resident with severe cognitive impairment and a PICC line for IV antibiotics did not receive care consistent with professional standards, as staff failed to document dressing changes, measure and record external catheter length, and assess arm circumference. After the resident pulled out the PICC line, there was no documentation of the total catheter length to confirm it was intact, and staff were unclear on protocols and documentation requirements.
Medication carts, medication rooms, and an OTC medication room were found unlocked and unattended, allowing potential access to drugs and biologicals by unauthorized individuals. Staff acknowledged that these areas should have been locked, and several residents with Alzheimer's disease or dementia resided on the affected units, increasing the risk of unauthorized access.
The facility did not ensure that meals were served at palatable and safe temperatures, as required by policy. Multiple residents reported receiving cold meals, and test trays on two units showed that hot foods were served below the required temperature and cold foods above the required temperature. Dietary staff and the FSD confirmed the temperature issues and attributed them to a malfunctioning plate warmer that had not been replaced.
Surveyors found that the facility did not properly label or date food items, allowed staff food in the main kitchen, and stored milk cartons on the floor. In a kitchenette, several food and drink items were undated or stored in broken containers, with some showing visible spoilage. Black mold-like residue was observed on kitchen surfaces, and staff were seen preparing food without required hair restraints.
The facility failed to maintain an effective infection control program, with incomplete infection surveillance records, unsecured treatment carts accessed by a resident without hand hygiene, and an oxygen concentrator filter used by a resident with COPD that was visibly dirty and not cleaned as required. Staff did not intervene when the resident accessed the carts, and documentation for infection surveillance was missing key information.
Staff did not create a baseline or comprehensive care plan within 48 hours of admission for a resident with PTSD and on antipsychotic medication, as required by facility policy. Although staff were aware of the resident's diagnoses and medication orders, no care plan was developed to address these needs, and this was confirmed by both the social worker and unit manager during interviews.
Surveyors found that two residents did not receive care consistent with professional standards: one resident did not have compression stockings applied as ordered, with no documentation to explain the omission, and another had an incomplete healthcare proxy invocation form, missing required details about incapacity. Staff interviews confirmed lapses in following and documenting physician orders and regulatory requirements.
A resident with PTSD, anxiety, and depression was not assessed for trauma history or potential triggers, and no individualized care plan was developed to address these needs. Staff, including the Director of Social Services, acknowledged the oversight, and documentation lacked details or interventions to prevent re-traumatization, contrary to facility policy.
A resident with a recent upper extremity fracture was provided a bed rail without an assessment for safety risks, review of risks and benefits, or informed consent. The facility's policy requiring interdisciplinary assessment, physician consultation, and documentation was not followed, and no care plan or physician order for the bed rail was found.
The facility failed to ensure that monthly pharmacist medication regimen review recommendations were addressed and documented for two residents, including one with COPD who did not have proper inhaler instructions added, and another receiving Seroquel without timely clarification or rationale for continued use. Staff interviews confirmed that the process for completing and recording these recommendations was not consistently followed.
The facility did not maintain complete and accurate medical records for two residents: one resident's healthcare proxy activation form was missing required information about incapacity, and another resident's administration of Tramadol was not consistently documented on the MAR, despite evidence from the narcotic count book. Staff interviews confirmed that these omissions resulted in incomplete and inaccurate records.
Essential kitchen equipment, including a microwave, food processor, and plate warmer, were not maintained in safe working order. A microwave in a resident kitchenette had a non-functional door button for about a week, the main kitchen's food processor was inoperable for several months unless bypassed with a magnet, and one column of the plate warmer was not working, requiring staff to rotate and cover plates to keep them warm. These issues were known to staff and had been reported but not addressed.
The facility failed to maintain sanitary conditions in two resident kitchenettes. Observations revealed mouse droppings, dried liquid stains, and food remnants in cabinets and on floors. The microwave was found with food remnants and soiled paper towels. Housekeeping admitted to inadequate cleaning practices, and the Corporate Consultant confirmed the need for thorough cleaning inside cabinets and microwaves.
A facility failed to label an opened Lantus insulin vial with the date opened and expiration date, as required by policy. This was observed during a surveyor's review of a medication cart. Nurse #1 and the DON confirmed the labeling requirement, noting the insulin's 28-day expiration period.
A resident with serious health conditions, including lung cancer and COPD, had an abnormal chest X-ray that was not communicated to the physician or nurse practitioner. The facility's policy required prompt notification of abnormal test results, but documentation showed no evidence of communication. Interviews revealed a breakdown in communication and documentation processes, with the Director of Nursing confirming the lack of notification.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that four residents had their call bell devices accessible and within reach while in their rooms, as required by facility policy. The policy specifies that call lights must be plugged in at all times and within easy reach of residents when they are in bed or confined to a chair. Multiple observations by the surveyor revealed that the call lights for these residents were consistently found on the floor or draped over the far side of nightstands, making them inaccessible to the residents. The residents involved had varying degrees of cognitive impairment and physical limitations, including histories of falls, dementia, pelvic fracture, chronic pain, and adult failure to thrive. Some residents were unable to locate their call lights or did not respond when asked about them, while others stated they could not find or reach their call lights. In several instances, the call lights were observed out of reach during multiple checks throughout the day, regardless of whether the residents were awake or asleep. Interviews with staff, including CNAs, nurses, the ADON, and the DON, confirmed that all residents should have access to their call lights, regardless of their ability to use them. Staff acknowledged that the call lights were not within reach and that this was not in accordance with facility policy. The deficiency was identified through repeated observations and staff interviews, which consistently demonstrated a lack of compliance with the requirement to keep call lights accessible to residents.
Failure to Ensure Resident Awareness and Access to Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully informed about the grievance process, as required by its own policy. During a resident group meeting attended by 10 residents from both facility units, several residents reported not having seen any postings about the grievance process and were unaware of how to file a grievance except by informing a staff member. Residents indicated that grievance forms were not readily accessible, and there was confusion about the ability to file grievances anonymously. One resident mentioned possibly seeing forms near the elevator but was unsure, and did not know who the grievance officer was. The majority of residents present agreed with these statements. Observations during tours of the facility revealed a lack of postings about the grievance process and limited access to grievance forms. On the second-floor unit, grievance forms were found only in a wall-mounted holder outside the social worker's office, which was not easily accessible to all residents, and there were no instructions for anonymous submission. The third-floor unit had no postings or available grievance forms, and an empty folder labeled grievances was found at the nursing station. The social worker acknowledged the absence of necessary postings and forms, and stated that the process for anonymous grievance submission had not been considered.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for five residents, resulting in deficiencies in meeting their specific care needs. For one resident with spinal stenosis and recent back surgery, the care plan for pain management was incomplete and not individualized, with many blank areas and lacking resident-specific information. Nursing staff did not consistently document pre- and post-medication pain assessments or the effectiveness of PRN pain medication, despite the resident receiving multiple doses. The medication administration record was not properly updated, and the effectiveness of pain interventions was not monitored as required by the care plan and facility policy. Two residents receiving antipsychotic medication (Seroquel) did not have care plans that identified the targeted behaviors, specific interventions, or measurable goals for the use of these medications. In both cases, staff and family interviews indicated that the residents did not exhibit the behaviors typically associated with the use of antipsychotics, and the care plans failed to include non-pharmacological interventions or rationale for the medication. The care plans were generic and did not reflect the residents' actual needs or conditions, and one resident's use of antipsychotic medication was not care planned at all. Additionally, after a resident sustained a fall, the facility did not implement or document any new interventions to minimize future falls, contrary to facility policy. Another resident using continuous oxygen therapy did not have a care plan addressing oxygen use, despite physician orders and the resident's significant cognitive impairment and respiratory needs. In each case, the lack of individualized, comprehensive care planning and failure to implement or document required interventions led to deficiencies in the facility's care delivery process.
Unsecured Treatment Cart and Improper Oxygen Cylinder Storage
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards due to lapses in supervision and improper storage of potentially harmful items. For one resident with severe cognitive impairment and moderate dementia, a wound treatment cart containing various topical medications and antiseptics was observed unlocked and unattended in a common area near the resident. The resident was seen rummaging through the cart multiple times, opening several drawers, while staff in the vicinity either did not intervene or failed to secure the cart. Interviews with nursing staff revealed they were unaware the cart was unlocked and did not have keys to lock it, despite facility policy requiring all medication storage areas to be locked when unattended. Another resident, also with significant cognitive impairment and a diagnosis of chronic obstructive pulmonary disease, had a freestanding oxygen cylinder (E-Tank) stored unsecured next to their nightstand and near their roommate's bed. The E-Tank was observed on multiple occasions over two days in the same unsecured position. Staff interviews confirmed that oxygen cylinders should not be left in resident rooms when not in use and, if present, must be secured in a cylinder stand or to a wheelchair. The E-Tank was neither secured nor properly stored according to facility policy and national fire safety codes. These deficiencies were confirmed through direct observation by surveyors and corroborated by staff interviews, which acknowledged the lapses in following established safety protocols for medication and oxygen storage. The facility's own policies and national safety standards were not adhered to, resulting in residents having access to accident hazards.
Failure to Maintain and Document PICC Line Care and Monitoring
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) consistent with professional standards of practice for one resident. The facility did not ensure documentation of PICC line dressing changes, did not measure and document the external catheter length to monitor for migration, did not measure and document arm circumference, and did not measure and document the total catheter length when the PICC line was pulled out by the resident. The facility's policy required these actions to prevent complications such as infection and catheter migration, but these were not followed or documented in the resident's medical record. The resident involved had severe cognitive impairment and was receiving IV antibiotics for sepsis through a PICC line. Upon observation, the resident was found with a PICC line in place but without a transparent dressing, and a loosely wrapped gauze was present instead. The resident was observed touching and playing with the PICC line. Nursing staff stated that a dressing change had been performed the previous day, but there was no documentation of this, nor of the required measurements of external catheter length or arm circumference. Additionally, after the resident pulled out the PICC line, there was no documentation of the total catheter length to confirm the catheter was intact, as required by policy and manufacturer guidelines. Interviews with nursing staff and facility leadership revealed a lack of clear orders for PICC line dressing changes and required measurements. Staff were unsure of the protocol for dressing changes and did not consistently document required information. The Medication Administration Record and Treatment Administration Record did not have designated areas for documenting these measurements. The absence of documentation and adherence to policy was acknowledged by staff and leadership during the survey.
Failure to Secure Medication Storage Areas
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with professional standards and its own policies. On one unit, a medication cart was observed unlocked and unattended in a hallway, with staff and others passing by. The nurse responsible for the cart acknowledged that it should have been locked but stated she was distracted and forgot to secure it. Additionally, both the 2nd and 3rd floor medication rooms were found unlocked and unattended at various times, with no licensed staff in the immediate vicinity. In one instance, a nurse was able to open the medication room door without a key, confirming it was not properly secured. The facility's policy requires all medication storage areas, including carts and rooms, to be locked when not in use or under direct supervision. The survey also found that the over-the-counter (OTC) medication room on one unit was unlocked and accessible, with shelves of medications available to anyone passing by. Nurses and the Director of Nursing confirmed that these areas should have been locked at all times when unattended. The report notes that several residents on the affected units had diagnoses of Alzheimer's disease or dementia, increasing the potential for residents to access and ingest medications if storage areas are not properly secured.
Failure to Serve Palatable Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and at appetizing temperatures on two units, as evidenced by observations, interviews, and meal test tray results. According to the facility's policy, hot foods should be maintained at or above 135°F and cold foods at or below 41°F. During a Resident Council Meeting, half of the participating residents reported that breakfast and lunch were often served cold and that there were not enough staff to pass trays. Test trays conducted on both the Second and Third Floor Units revealed that several hot food items, such as scrambled eggs, waffles, and sausage, were served at temperatures below the required threshold and were described as lukewarm or cold and lacking flavor. Cold items, such as milk and orange juice, were also served above the required cold temperature, with some items being lukewarm to taste. Interviews with dietary staff and the Food Service Director (FSD) confirmed that the food temperatures were not within the appropriate ranges and did not meet expectations for palatability. The FSD acknowledged that one column of the plate warmer had not been working for some time, requiring staff to rotate hot plates and cover them with a pot as a workaround. The FSD stated that the kitchen needed a new plate warmer and that all staff were aware of the issue. These actions and inactions led to the deficiency in serving meals at safe and appetizing temperatures.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as evidenced by multiple observations in both the main kitchen and a kitchenette. Surveyors found that food items in the main kitchen walk-in refrigerator were not properly labeled or dated, including an opened container of thickened cranberry juice and a pouch of whipped cream, both lacking required date markings. Additionally, milk cartons were stored directly on the floor, and staff members' personal food and beverages were found in the main kitchen refrigerator, contrary to facility expectations. The Food Service Director (FSD) confirmed that all foods should be labeled with the date opened and use-by date, and that staff food should be stored in the employee break room, not the main kitchen. In the third-floor kitchenette, surveyors observed several food and drink items that were not properly labeled or dated, including open containers of nutritional drinks and dairy-free milk, as well as resident-provided foods that were undated or stored in broken containers. Some items were found with visible spoilage, such as a container with a black fuzzy substance under the cover. The FSD stated that foods from home should be labeled with the resident's name and date brought in, and that expired or spoiled foods should be discarded. Despite these expectations, the surveyor repeatedly found improperly stored and labeled items during multiple visits. Sanitation issues were also identified in both the main kitchen and the kitchenette. The wall behind the dishwashing station in the main kitchen and the countertop next to the sink in the kitchenette were observed on several occasions to have black mold-like residue. The FSD and other staff acknowledged the presence of this residue and attributed it to moisture and water splashing, but it was not adequately addressed. Additionally, staff were observed preparing and serving food without appropriate hair restraints, and the hair net holder in the kitchen was empty. The FSD confirmed that staff should not be near food preparation areas without proper hair or beard covers.
Infection Control Program Deficiencies: Incomplete Surveillance, Unsecured Treatment Carts, and Unclean Oxygen Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance documentation, unsecured treatment carts accessible to residents, and unclean oxygen concentrator filters. The Infection Preventionist (IP) did not ensure that infection surveillance line listings for multiple months included all required information, such as complete symptom listings, culture site and results, and infection clearance status for healthcare-associated infections (HAIs) like skin infections, urinary tract infections (UTIs), and pneumonia. The IP acknowledged that the line listings should be complete and that missing information was not acceptable. Treatment carts on the third floor were repeatedly observed to be left unlocked and unattended, allowing a resident to open drawers and touch items inside without performing hand hygiene. Both housekeeping and CNA staff witnessed the resident accessing the carts but did not intervene or alert nursing staff. The ADON/IP confirmed that treatment carts should always be locked and that residents should not have access to their contents, as this constitutes a breach of infection control protocols and compromises the items inside the carts. Additionally, a resident with chronic obstructive pulmonary disease (COPD) was observed using an oxygen concentrator with a filter that was caked with dust and debris over multiple days. Although there was a physician's order to clean the filter weekly, the filter was visibly dirty, and staff could not confirm when it was last cleaned. The DON stated that oxygen equipment should be clean and follow infection control protocols, but the lack of regular cleaning and documentation led to the deficiency.
Failure to Develop Baseline Care Plan for Resident with PTSD and Antipsychotic Use
Penalty
Summary
Staff failed to develop a baseline or comprehensive care plan within 48 hours of admission for a resident with multiple diagnoses, including PTSD, anxiety, depression, and a recent fracture. The facility's policy requires that a baseline care plan be created within 48 hours to address immediate needs, including initial goals, physician's orders, dietary needs, therapy, social services, and PASARR recommendations. However, review of the resident's records showed that no care plan was developed within the required timeframe to address the resident's PTSD diagnosis or the use of the antipsychotic medication Quetiapine (Seroquel). Interviews with facility staff confirmed awareness of the resident's PTSD diagnosis and antipsychotic medication order, but acknowledged that a care plan addressing these needs was not created as required. The social worker stated she was aware of the PTSD diagnosis but did not know the resident's trauma history or triggers and admitted that a care plan should have been developed but was not. The unit manager also confirmed that no baseline or comprehensive care plan was found in the resident's record to address the use of antipsychotic medication.
Failure to Apply Compression Stockings and Incomplete Healthcare Proxy Invocation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents. For one resident with chronic kidney disease, congestive heart failure, and dementia, there was a physician's order for daily application of compression stockings to both lower extremities. Despite this order, multiple observations over two days showed the resident did not have compression stockings applied, and their lower extremities were swollen and discolored. The Medication Administration Record (MAR) indicated the stockings were applied as ordered, but there was no documentation in the medical record to support that the order was on hold, discontinued, or that the resident refused the intervention. Nursing staff were unclear about their responsibility to check for the application of compression stockings throughout the day, and facility leadership confirmed that documentation should be present if the order was not followed. For another resident with dementia and severe cognitive impairment, the healthcare proxy (HCP) was invoked by a nurse practitioner due to cognitive decline. The HCP invocation form, however, was incomplete; specifically, the sections for the cause and nature of the incapacity were left blank, although the extent and probable duration were documented. The nurse practitioner acknowledged the error and stated that completing the cause and nature is standard practice. Facility leadership also confirmed that the HCP invocation form should be fully completed in accordance with regulatory requirements. These deficiencies were identified through observation, interview, and record review, and were found to be inconsistent with professional standards of quality and regulatory requirements as outlined by the Massachusetts Board of Registration in Nursing and state law regarding healthcare proxy activation.
Failure to Assess and Plan Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history and related care needs of a resident with a documented diagnosis of PTSD, anxiety, and depression. Despite the facility's policy requiring trauma assessments and individualized care planning, there was no evidence in the medical record that staff collaborated with the resident or other healthcare professionals to identify the nature of the trauma, its effects, or potential triggers. The psychiatric nurse practitioner's documentation acknowledged the PTSD diagnosis but did not provide details about the trauma or interventions to mitigate re-traumatization. Interviews with the resident confirmed a history of significant trauma in both childhood and adulthood. The Director of Social Services admitted to missing the trauma assessment and care plan for this resident, despite being aware of the PTSD diagnosis. Additionally, the Unit Manager and Regional Nurse were unable to identify the nature of the resident's trauma or any specific triggers, indicating a lack of comprehensive assessment and person-centered planning as required by facility policy.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for the use of a bed rail, as required by its own policy and regulatory standards. Specifically, the facility did not conduct an assessment to identify the reason for using the side rail or evaluate the risk of entrapment. There was no evidence of an interdisciplinary assessment, consultation with a physician or nurse practitioner, or input from the resident or their legal representative regarding the benefits and potential hazards associated with side rail use. Additionally, the facility did not obtain informed consent from the resident or their representative prior to the installation of the bed rail. The deficiency was identified for a resident who was admitted following a left proximal humerus fracture after a fall at home. The resident was cognitively intact but had functional limitations in the upper and lower extremity on one side. Observations showed a bed rail attached to the left side of the resident's bed, which the resident could not use for repositioning due to pain and limited mobility. Review of the medical record revealed no physician's order, no care plan, and no signed consent for the use of the bed rail, despite the facility's policy requiring these steps.
Failure to Address and Document Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the consultant pharmacist recommended that instructions be added to the physician's order for Trelegy Ellipta inhaler to rinse the mouth after use to prevent oral thrush. This recommendation, made in February, was not addressed by the physician, and there was no documentation in the medical record indicating that the recommendation had been acted upon. For another resident with dementia and anxiety, who had been receiving Seroquel since admission, the consultant pharmacist made multiple recommendations over several months. These included requests for a psychiatric consult to review the appropriateness of Seroquel, consideration of a gradual dose reduction, and clarification or update of the diagnosis associated with the medication. The responses to these recommendations were either incomplete, lacking a rationale for continued use, or not documented at all. The diagnosis for Seroquel was eventually changed from sleep to depression, but there was no documentation in the medical record to indicate that the pharmacist's recommendations from August or January had been addressed. Interviews with facility staff confirmed that the process for addressing and documenting MRR recommendations was not consistently followed. The Unit Manager and DON acknowledged that recommendations were not always completed or uploaded into the electronic medical record as required, and the consultant pharmacist reported that his recommendations were not routinely addressed or documented by his next visit, as expected by facility policy.
Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with dementia and severe cognitive impairment, the healthcare proxy (HCP) activation form was not fully completed. Specifically, the section requiring documentation of the cause and nature of the resident's incapacity was left blank by the nurse practitioner who invoked the HCP. Both the Director of Nursing (DON) and the Administrator confirmed that the form was incomplete, making the medical record inaccurate for this resident. For another resident admitted with spinal stenosis and post-laminectomy, the administration of Tramadol, a pain medication, was not consistently documented on the Medication Administration Record (MAR). Although the narcotic count book showed that 13 doses of Tramadol were dispensed over several days, these administrations were not recorded on the MAR. The nurse responsible acknowledged that she had administered the medication but failed to document it as required. Interviews with facility staff, including the DON and the Administrator, confirmed that the expectation is for all medication administrations and relevant medical information to be accurately and completely documented in the residents' medical records. The lack of documentation resulted in incomplete and potentially inaccurate records for both residents involved.
Failure to Maintain Kitchen Equipment in Safe Working Order
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order, as evidenced by multiple observations and staff interviews. On two separate occasions, a microwave in the third-floor resident kitchenette was found to have a non-functional door open button, preventing its use. The Food Service Director (FSD) confirmed that the microwave had been broken for about a week and that maintenance had been notified, but no repairs had been made. The microwave was used by residents to heat their own food or to have staff heat food for them, and the facility's policy required all kitchen equipment to be kept functional. Additionally, the main kitchen's food processor, used to puree food for residents, was demonstrated to be inoperable unless a magnet was used to bypass a safety feature. Staff reported that the food processor had been broken for six months to a year and that it had been reported to both the FSD and maintenance, but it remained unfixed. Furthermore, one column of the plate warmer in the main kitchen was not working, requiring staff to rotate plates and cover them with a pot to keep them warm. The FSD stated that the plate warmer had not been working for some time, and the need for a replacement was known among staff.
Failure to Maintain Sanitary Conditions in Resident Kitchenettes
Penalty
Summary
The facility failed to maintain two resident nourishment kitchenettes in a clean and sanitary condition, as observed by the surveyor. On the Third-floor kitchenette, there were mouse droppings and dried liquid stains around a metal pest trap under the sink, and additional stains and food remnants were found in the cabinets. A sticky dried liquid stain was also noted on the floor in front of the refrigerator. On the Second-floor kitchenette, the microwave was found with food remnants and heavily soiled paper towels, and the floor was tacky with visible food remnants. A large food stain was also present on the wall and floor near the radiator. During interviews, Housekeeper #1 admitted to only wiping down the outside of the microwave and acknowledged the need for better cleaning practices, including the inside of the microwave and the floor. The Corporate Consultant confirmed that housekeeping should be responsible for cleaning inside the cabinets and microwaves and ensuring the floors are clean and free from food. Despite the facility's policy requiring regular cleaning, these observations indicated a failure to adhere to the established standards for maintaining sanitary conditions in the kitchenettes.
Failure to Properly Label Insulin Vials
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly labeled in accordance with currently accepted professional principles. Specifically, the deficiency was observed in one of the three medication carts reviewed, where an opened multiple dose injection vial of Lantus (insulin glargine) was found without a label indicating the date it was opened or its expiration date. This oversight was noted during a surveyor's review of the 3rd floor unit main side medication cart. During interviews, Nurse #1 acknowledged that the insulin packaging box and vial should have been labeled with the open date and expiration date, as the insulin has a shortened expiration period of 28 days. The Director of Nurses (DON) confirmed that staff are required to label medications, including insulin, with the date opened and expiration date to ensure they are removed and replaced once expired. The failure to label the insulin vial and packaging correctly was a deviation from the facility's policy on medication storage.
Failure to Notify Physician of Abnormal X-ray Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of an abnormal chest X-ray for a resident who was admitted with multiple serious health conditions, including metastatic squamous cell carcinoma of the larynx, primary lung cancer, pneumonia, and chronic obstructive pulmonary disease (COPD). The resident had a history of acute hypoxic respiratory failure and pleural effusion requiring drain placements. A stat chest X-ray was ordered on March 9, 2024, due to the resident's respiratory distress, but the results indicating significant abnormalities were not communicated to the medical team. The facility's policy required that nursing staff promptly notify the attending physician of any abnormal test results, especially when the resident's clinical status is unstable. However, the documentation review revealed that the X-ray results, which showed near-complete opacification of the left lung and other concerning findings, were not communicated to the physician or nurse practitioner. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record indicating that the medical team was informed of the X-ray results. Interviews with nursing staff and the DON indicated a breakdown in communication and documentation processes. The nurse who ordered the X-ray left the responsibility of following up on the results to the next shift, but the results were not communicated. The DON and nurse practitioner confirmed that there was no record of the X-ray results being shared with the medical team, and the secure electronic system used for communication automatically deleted older messages, further complicating the situation.
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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