Regalcare At Taunton
Inspection history, citations, penalties and survey trends for this long-term care facility in Taunton, Massachusetts.
- Location
- 68 Dean Street - Rear, Taunton, Massachusetts 02780
- CMS Provider Number
- 225474
- Inspections on file
- 22
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regalcare At Taunton during CMS and state inspections, most recent first.
A resident with severe cognitive impairment became combative during care, prompting a CNA to threaten retaliation and then slap the resident's hand twice, causing the resident to cry out in pain. The incident, witnessed by another CNA, violated facility policy prohibiting physical abuse and the requirement to treat all residents with dignity and respect.
A CNA failed to immediately report witnessing another CNA physically abuse a resident with severe cognitive impairment during care. Instead of notifying the nurse on duty as required by policy, the CNA delayed reporting the incident until several hours later, resulting in noncompliance with the facility's abuse identification and reporting procedures.
A resident with a heart transplant missed 40 doses of tacrolimus after the medication was erroneously discontinued following hospital readmission. The facility's medication reconciliation process failed to resolve discrepancies, and multiple staff did not identify the omission despite reviewing the medication list. The error was only discovered after the resident's cardiology team noted a critically low tacrolimus level and contacted the facility, resulting in the resident requiring hospitalization for rejection surveillance and medication adjustments.
Residents repeatedly raised concerns about long call bell wait times during Resident Council meetings, but the facility failed to document follow-up actions or provide timely responses. Interviews confirmed that residents did not receive updates or see improvements, and staff could not provide evidence of resolution for the concerns raised.
The facility did not ensure residents had access to information about the grievance process, failed to provide grievance forms in accessible areas, and did not consistently investigate or resolve grievances. Residents and staff were unclear about how to file grievances and who was responsible for addressing them, and the Ombudsman and residents did not receive updates on reported concerns.
A resident with a heart transplant did not receive tacrolimus after hospital readmission due to failures in medication reconciliation, lack of timely pharmacy review, and poor communication of abnormal lab results. The facility's assessment did not address the use of lab or pharmacy services, and staff had not received prior training on medication reconciliation or provider notification of abnormal labs, resulting in missed doses and delayed provider notification.
A resident with multiple mental health diagnoses was admitted without a completed Level I PASARR screening, which was only submitted after admission. The resident later required a Level II PASARR evaluation that identified the need for specialized behavioral health services. Staff confirmed there was no documentation of the required pre-admission screening.
Surveyors identified that two residents did not receive care according to their individualized care plans: one required two staff for all care due to behavioral concerns but was routinely cared for by a single CNA, and another with impaired vision was left without eyeglasses, with staff unaware of the need and unable to locate the glasses. These findings were confirmed through observation, interviews, and record review, showing a lack of adherence to documented care interventions.
A resident with a history of organ transplant missed 40 doses of tacrolimus after a hospitalization due to the facility's failure to update and implement the new medication regimen and follow-up lab monitoring as recommended by the hospital. The abnormal tacrolimus level was not addressed in a timely manner, and the medical staff did not ensure proper communication or supervision of the resident's care, resulting in the resident's emergent transfer for transplant rejection surveillance.
Two residents did not receive required face-to-face visits from a physician or NP/PA within the mandated timeframes. One resident was not seen by a physician within 30 days of admission, and another went 199 days without a physician visit, with visits not alternating as required.
Nursing staff did not demonstrate competency in managing immunosuppressant therapy for a resident with a heart transplant, resulting in missed doses of tacrolimus and delayed communication of abnormal lab results. The resident was not given the prescribed medication for over two weeks, and staff failed to notify the consulting team about low drug levels, leading to hospital transfer for organ rejection surveillance. Staff education records showed no prior training on immunosuppressant management or lab result reporting.
A resident with a heart transplant missed 40 doses of tacrolimus after readmission because a required pharmacist medication regimen review was not completed, and a medication reconciliation error led to the discontinuation of the immunosuppressant. The omission was not identified until the resident required hospitalization, and interviews confirmed that admission medication reviews were not consistently performed during this period.
A resident with a history of organ transplant experienced a medication error when tacrolimus was discontinued in error after hospital readmission, resulting in delayed lab draws and lack of timely communication with the transplant team. The facility failed to complete a pharmacy AMRR and did not ensure effective QAPI oversight, leading to missed opportunities to identify and address the deficiencies.
The facility did not provide required training on its Quality Assurance and Performance Improvement (QAPI) program to all staff, as evidenced by a review of education records and staff interviews. Multiple staff members, including nurses, a unit manager, a social worker, and the staff development coordinator, confirmed they had not received QAPI training or were unfamiliar with the program's goals and their roles in it.
Quarterly MDS assessments were not completed within the required timeframe for five residents. Some assessments were completed late, while others were not completed at all, as confirmed by the Regional Nurse during the survey. This deficiency was identified through review of assessment records and staff interviews.
Nurse staffing information, including actual hours worked by RNs, LPNs, and CNAs, was not updated daily as required. The posted document was observed to be outdated, and staff interviews confirmed that the process for updating the information was not consistently followed.
The facility failed to follow up on psychiatric recommendations for two residents requiring interventions. One resident's recommendation for Sertraline was not communicated to the physician, while another's recommendation for Citalopram was delayed by 16 days. Staff interviews revealed a breakdown in communication and follow-up procedures.
The facility's kitchen had significant sanitation issues, including unsanitary conditions in the walk-in refrigerator, improper labeling and dating of food items, and inadequate hand hygiene practices among staff. Despite policies in place, these deficiencies persisted, as observed by the surveyor.
The facility failed to ensure all residents could participate in the Resident Council and did not document or resolve grievances within the required timeframe. The Activity Director misunderstood participation rights, leading to selective invitations. Grievances about call light response times and other issues were repeatedly raised without timely resolution. Staff interviews revealed inadequate documentation and follow-up, with the Administrator not yet involved in the grievance process.
The facility failed to maintain professional standards for three residents, leading to deficiencies in care. A resident's weekly skin assessments lacked detailed documentation, another resident did not receive all prescribed doses of Debrox Otic Solution, and a third resident had an incomplete physician's order for Trazodone. Interviews with staff confirmed these deficiencies, highlighting lapses in documentation and medication administration.
The facility failed to ensure timely physician visits for four residents, as required by policy and OBRA regulations. A resident with severe cognitive impairment and diabetes had a 143-day gap between visits, while another with congestive heart failure had a 197-day gap. Despite the physician and NP alternating visits every 90 days, records did not show evidence of required visits.
The facility failed to ensure that Arbitration Agreements were explained to residents in a comprehensible manner. Interviews revealed that residents were either unfamiliar with the agreement or did not recall it being explained. The DOA admitted to not informing residents that signing was not a condition of admission or that they were waiving their right to a court trial. The Administrator was unfamiliar with the process.
The facility's arbitration agreement did not ensure the selection of a neutral arbitrator and venue convenient for both parties. The Director of Admissions confirmed the absence of such provisions, but an updated agreement was later provided.
A resident experienced a significant weight loss, but the facility failed to notify the physician as required by their policy. The resident, admitted with conditions like failure to thrive and lymphedema, lost 7.17% of their weight in a short period. Despite the facility's policy to notify physicians of such changes, there was no documentation of notification, and staff interviews confirmed the physician was unaware of the weight loss until much later.
Two residents experienced neglect due to delayed responses to call lights. One resident with Multiple Sclerosis waited 40 minutes for assistance with personal hygiene, while another resident with hemiplegia waited 48 minutes for toileting help, resulting in soiling. The DON acknowledged that staff should respond promptly to call lights.
A resident with COPD and CHF was observed receiving non-humidified oxygen at 1.5 liters per minute, contrary to physician's orders for humidified oxygen at 2 liters per minute at bedtime. The Treatment Administration Record inaccurately reflected the administration of humidified oxygen, highlighting a discrepancy in care.
A facility failed to ensure proper communication with a dialysis center for a resident with end-stage renal disease. The resident's dialysis communication forms were often incomplete, lacking essential information such as meal times and medications. Interviews with staff revealed that the forms were expected to be filled out but were not, indicating a lapse in adherence to facility policies.
A facility failed to ensure a consultant pharmacist identified and reported an incomplete medication order for Trazodone during a monthly drug regimen review. A resident with severe cognitive impairment and diagnoses of anxiety and depression had a physician's order for Trazodone that lacked the necessary tablet strength specification. The consultant pharmacist acknowledged the oversight during an interview, admitting the error should have been identified during the review.
The facility failed to accurately complete MDS assessments for two residents, leading to documentation errors. One resident's MDS did not reflect their dialysis treatment, while another's discharge status was incorrectly recorded as being to an acute hospital instead of home with services. These inaccuracies were confirmed by facility staff during interviews.
CNA Physically Abuses Cognitively Impaired Resident During Care
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with dementia, anxiety disorder, and major depressive disorder, became combative during incontinence care. During this episode, a Certified Nurse Aide (CNA) responded to the resident's physical aggression and verbal insults, including a racial slur, by threatening retaliation, stating, "If you hit me again, I will hit you back." The CNA then forcefully grabbed the resident's left wrist and slapped the top of the resident's left hand twice, causing the resident to yell out in pain. This incident was directly witnessed by another CNA who was assisting with care and reported that the slaps were hard enough to be audible. The facility's policy prohibits all forms of abuse, including physical abuse such as hitting and slapping, and requires that residents be treated with respect and dignity at all times. The incident was reported through the Health Care Facility Reporting System, and interviews with staff confirmed the sequence of events, including the verbal threat and physical action by the CNA. The resident's severe cognitive impairment was noted, but it was acknowledged that an unimpaired individual would have experienced pain and mental anguish from such treatment.
Failure to Immediately Report Witnessed Abuse
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to immediately report an incident of physical abuse witnessed during care of a resident with severe cognitive impairment. The facility's policy required that any suspected abuse be reported immediately to the administrator or designee. During the night shift, CNA #1 observed CNA #2 respond to a combative resident by threatening retaliation and then forcibly grabbing the resident's wrist and slapping the back of the resident's hand twice. The resident, who had diagnoses including dementia, anxiety disorder, and major depressive disorder, yelled out in response to the slaps. Despite witnessing the incident, CNA #1 did not report it to the nurse on duty as required by facility policy. Instead, CNA #1 completed her shift, went home, and only returned to the facility approximately two hours later to report the incident to the nurse. The delay in reporting was confirmed through interviews and review of written statements, and the Director of Nursing acknowledged that the immediate reporting requirement was not followed.
Failure to Prevent Significant Medication Error: Missed Immunosuppressant Doses
Penalty
Summary
A resident with a history of heart transplant, heart failure, and stroke was readmitted to the facility following a hospitalization for heart failure exacerbation. Upon discharge from the hospital, the resident was prescribed tacrolimus, an immunosuppressant medication, with a revised dosing schedule. The facility's medication reconciliation process identified potential clinically significant medication issues, but the documentation did not specify the discrepancies or their resolutions. An order for tacrolimus was entered into the physician's orders but was subsequently discontinued the same day, resulting in the resident not receiving any tacrolimus from the following day until nearly three weeks later. During this period, the resident missed 40 doses of tacrolimus. Progress notes and medication records failed to document the discontinuation or provide a rationale for stopping the medication. Multiple staff, including the physician and physician assistant, did not identify the omission of tacrolimus in the resident's regimen, despite reviewing the medication list and being aware of the resident's transplant status. The facility's pharmacy consultant also reviewed the medication regimen during this time and did not note any irregularities. Communication breakdowns were evident, as the resident's cardiology team repeatedly attempted to obtain updated medication lists and lab results from the facility but encountered significant barriers and delays. The error was ultimately discovered when the cardiology team noted a critically low tacrolimus level and contacted the facility, at which point it was confirmed that the resident had not received the medication. The resident required emergent hospitalization for rejection surveillance and medication adjustments. Interviews with facility staff revealed a lack of awareness regarding the discontinuation of tacrolimus and a failure to identify or address the medication error until notified by the external cardiology team.
Failure to Document and Address Resident Council Concerns on Call Bell Wait Times
Penalty
Summary
The facility failed to ensure that concerns raised by the Resident Council, particularly regarding long call bell wait times, were thoroughly documented and addressed in a timely manner. Review of Resident Council minutes over a six-month period showed that residents repeatedly voiced concerns about call bell wait times at five out of six meetings. However, the facility was unable to provide documentation of resolution or follow-up for these concerns in the minutes from January and February. The only resolution plan noted was an ongoing audit, with no additional follow-up recorded. Interviews with the Resident Council President and a group of residents confirmed that the issue of call bell wait times was a recurring topic without any apparent resolution, improvement, or communication from staff about actions taken. The Activities Director stated that follow-up forms were to be completed and given to the responsible department, but could not provide information about meetings prior to her employment. The Director of Operations indicated that the grievance policy should be fully followed, including follow-up on concerns raised at Resident Council meetings.
Failure to Ensure Resident Access to and Resolution of Grievances
Penalty
Summary
The facility failed to ensure that residents were able to voice and formulate grievances, have those grievances responded to promptly, and be provided with a resolution. During a facility tour, the surveyor was unable to find information about the grievance process posted in resident care areas, and the only information available was in the main lobby, which was not accessible to all residents. Review of the grievance binder showed the last grievance was resolved over a month prior to the survey, and during a resident group meeting, residents reported not seeing any postings about the grievance process and not knowing how to file a grievance except by reporting to staff. Residents also expressed uncertainty about the location of grievance forms and the identity of the grievance officer. Interviews with facility staff revealed confusion regarding the grievance process and the identity of the grievance officer. The Administrator, who had been in the role for about a month, was unsure about the previous process and stated that the social worker was responsible for grievances, while the social worker indicated that the Administrator was the grievance officer. The Activities Director was also unsure who the grievance officer was or who was responsible for providing updates and resolutions. The Ombudsman reported that concerns and grievances were submitted to administration but was not informed of any updates or resolutions, and residents she communicated with also did not receive updates on their reported concerns.
Failure to Ensure Medication Reconciliation and Oversight After Hospital Readmission
Penalty
Summary
The facility failed to provide appropriate administrative oversight in clinical management, resulting in a resident not receiving tacrolimus, an immunosuppressant medication, after readmission from the hospital. The facility's Facility Assessment did not address the use of laboratory or pharmacy services, nor did it outline how discrepancies or concerns from these services would be communicated to administration. The assessment also lacked evidence of regular staff education or competency validation related to medication reconciliation, laboratory result reporting, or communication with consulting providers prior to the incident. A resident with a history of heart transplant, stroke, and heart failure was readmitted to the facility following a hospitalization for heart failure exacerbation. Upon return, the resident's medication regimen had changed, including the need for ongoing tacrolimus therapy. The medical record showed that the resident missed 40 doses of tacrolimus over a period of several weeks. The medication reconciliation assessment identified potential issues but did not specify the problems or their resolution. Additionally, an Admission Medication Regimen Review (AMRR) was not completed by the consultant pharmacist within the required timeframe after the resident's readmission, and abnormal laboratory results indicating a low tacrolimus level were not promptly communicated to the cardiology team. Interviews revealed that there was confusion and lack of communication among facility staff, pharmacy, and consulting providers. The acting DON and other staff were unaware of the missed AMRRs and medication errors until notified by external parties. The medication error was not fully investigated, as the facility's Performance Improvement Plan did not address the missed AMRR or the failure to notify the cardiology office of abnormal lab results. The incident was not reported to the governing body, and there was no evidence of prior staff education on medication reconciliation or provider notification of abnormal labs before the event.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASARR) for one resident prior to admission. The resident was admitted with multiple mental health diagnoses, including post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. The Minimum Data Set (MDS) assessments indicated the resident was cognitively intact, and additional mental health diagnoses were documented upon admission. However, the Level I PASARR was not submitted for review until after the resident had already been admitted to the facility. Subsequently, the resident required a Level II PASARR evaluation, which was completed after admission and determined that the resident met the criteria for serious mental illness (SMI) and required specialized or behavioral health services. Interviews with facility staff confirmed that there was no documentation showing the Level I PASARR was completed prior to admission, and it was acknowledged that the expectation is for this screening to be completed before admitting residents.
Failure to Implement Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to implement person-centered care plans for two residents, resulting in deficiencies related to staff adherence to documented interventions. For one resident with a history of cerebral infarction and behavioral issues, the care plan required two staff members to be present for all care due to a history of sexually inappropriate and accusatory behaviors. Despite this, multiple CNAs reported providing care to the resident alone, and direct observation confirmed that care was delivered by a single staff member. The unit manager confirmed the ongoing need for two-person care, and the DON stated that staff should have access to and follow the care plan at all times. For another resident with moderate cognitive impairment and impaired vision, the care plan specified that the resident should use eyeglasses to support participation in daily activities. The resident reported not having their glasses and being unable to see, and was observed without glasses in the day room. Staff members were unaware of the resident's need for glasses, and the unit manager initially stated the resident did not wear glasses. Upon further investigation, the resident's glasses could not be located, and the unit manager acknowledged missing this requirement in the care plan. The resident's son confirmed the glasses had been missing for about two months and had requested assistance in replacing them. These deficiencies were identified through observation, interviews, and record review, demonstrating a failure to implement and follow individualized care plans as documented for both residents. The lack of adherence to care plan interventions was confirmed by staff interviews and direct observation, with care plans not being consistently referenced or followed during care delivery.
Failure to Provide Physician Oversight for Immunosuppressant Medication Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or physician assistant (PA) provided adequate supervision and oversight for the care of a resident with a history of organ transplant who required daily tacrolimus, an immunosuppressant medication. After a hospitalization, the resident's medication regimen was changed, including a new dosing schedule for tacrolimus and a recommendation for follow-up laboratory monitoring. However, upon the resident's return to the facility, the updated tacrolimus regimen was not correctly identified or implemented by the facility's medical staff. The resident missed a total of 40 doses of tacrolimus over several weeks, as the medication was not prescribed from the time of readmission until nearly three weeks later. Additionally, the required follow-up tacrolimus level was not ordered on the recommended date, and when a tacrolimus level was eventually drawn and found to be low, there was no timely intervention or adjustment to the medication regimen. The PA reviewed the abnormal lab result but did not document any follow-up actions or new orders, and did not confirm whether the results were communicated to the resident's cardiologist as required. Progress notes from both the physician and PA failed to reflect the updated medication orders and monitoring recommendations from the hospital discharge summary. Both the physician and PA were unaware of the missed doses and abnormal lab results until notified by the resident's cardiology team. The facility's records did not show that the medical staff adequately reviewed or acted upon the hospital's recommendations, nor did they ensure that the resident's care was properly supervised according to facility policy.
Failure to Provide Timely Physician and Provider Visits
Penalty
Summary
The facility failed to ensure that residents received timely and appropriate visits from a Physician, Nurse Practitioner (NP), or Physician's Assistant (PA) as required by regulations and facility policy. For one resident with a spinal cord injury and paraplegia, there was no evidence of a physician visit within 30 days of admission, with the first documented physician visit occurring five months after admission. The facility's own policy and federal regulations require that new admissions be seen by a physician within 30 days, but documentation and interviews confirmed this did not occur for this resident. Additionally, another resident with multiple diagnoses, including type 2 diabetes mellitus with diabetic neuropathy, dysarthria following cerebral infarct, hemiplegia, hemiparesis, pain, and major depressive disorder, was not seen by a physician for a period of 199 days. During this time, required visits did not alternate between the physician and NP/PA as mandated. The Regional Director of Operations confirmed that the resident was not seen by a physician every 60 days and that the required alternation of visits did not occur during the specified period.
Failure to Ensure Nursing Staff Competency in Immunosuppressant Drug Therapy
Penalty
Summary
Nursing staff failed to demonstrate competency in managing immunosuppressant drug therapy for a resident with a history of heart transplant. Upon the resident's readmission following hospitalization for heart failure exacerbation, the hospital discharge summary specified a revised tacrolimus regimen and required follow-up lab monitoring. However, the facility's medication reconciliation process did not clearly document the resolution of medication discrepancies, and the resident's tacrolimus was discontinued shortly after readmission, resulting in a gap where no doses were administered for over two weeks. The resident missed 40 doses of tacrolimus between late February and mid-March, as evidenced by the medication administration records. Additionally, the required tacrolimus level was not drawn on the specified date, and when it was eventually obtained, the abnormally low result was not promptly communicated to the consulting heart failure team for further recommendations. The lack of timely notification and follow-up led to the resident being transferred to the hospital for organ rejection surveillance and medication adjustments. Interviews and review of staff education files revealed that nurses assigned to the resident's care had not received prior education or in-service training on immunosuppressant medication management or laboratory result reporting. The facility's education binder confirmed the absence of relevant training before the incident. Facility policies required prompt physician notification of abnormal lab results and significant changes in treatment, but these protocols were not followed in this case.
Failure to Complete Timely Pharmacist Medication Review Leads to Missed Immunosuppressant Doses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed pharmacist performed an Admission Medication Regimen Review (AMRR) for a resident who was readmitted after a hospital stay. The resident, who had a history of heart transplant and was dependent on staff for activities of daily living, required ongoing immunosuppressant therapy with tacrolimus to prevent organ rejection. Upon readmission, the resident's medication orders were changed, and a discrepancy occurred in the transcription and continuation of tacrolimus, resulting in its discontinuation. The facility's policy required medication reconciliation at admission or readmission, including a review of all medications and identification of discrepancies. However, after the resident returned from the hospital, there was no evidence that an AMRR was completed by the consultant pharmacist within the required timeframe. The resident's medical record showed that the tacrolimus order was discontinued on the day of readmission, and no pharmacy review was documented until several days later. As a result, the resident missed 40 doses of tacrolimus over a period of approximately three weeks. Interviews with facility staff and pharmacy management confirmed that AMRRs were not consistently completed during the relevant period, and that the missed review contributed to the failure to identify the medication omission. The error was only discovered after the resident required emergent hospitalization due to missed doses. The facility's own incident report and performance improvement documentation acknowledged the medication was not administered due to incorrect entry in the electronic health record and lack of timely pharmacy review.
Failure to Implement Effective QAPI and Medication Reconciliation Processes
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP) to address quality deficiencies related to delayed laboratory result reporting, readmission medication reconciliation, and pharmacy Admission Medication Regimen Review (AMRR) after admission or readmission. The facility's QAPI policy required systematic monitoring and analysis of performance to improve resident outcomes, with specific benchmarks and input from staff, residents, and families. However, documentation and interviews revealed that these processes were not effectively followed in the case reviewed. A resident with a history of stroke, heart failure, and organ transplant was admitted to the facility and required close monitoring of tacrolimus levels as part of immunosuppressive therapy. Physician's orders specified regular lab draws and communication of results to the transplant team. After a hospital readmission, the resident's tacrolimus was discontinued in error, and there was a significant delay in obtaining and reporting lab results. The medical record did not show that the required AMRR was completed by the consultant pharmacist after the resident's return from the hospital. Additionally, the facility failed to communicate abnormal lab results to the transplant team in a timely manner, and the medication error was not promptly identified or addressed. Interviews with facility staff and external care providers indicated breakdowns in communication, lack of follow-through, and confusion regarding education provided to staff about medication reconciliation procedures. The Cardiology RN reported extensive difficulties in obtaining updated medication lists and lab results from the facility, and the facility's documentation did not reflect that the QAPI committee had identified or addressed all aspects of the deficiency, including missed lab draws, lack of AMRR, and communication failures. The PIP lacked established benchmarks or targets for monitoring performance improvement activities.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training and education to all staff regarding the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. According to the facility's own policy, small group education sessions on QAPI are to be provided to all caregivers, and QAPI is included in orientation for new staff. The administrator is responsible for ensuring ongoing orientation, education, and training on QAPI, and staff are expected to answer questions about performance improvement during annual evaluations. However, a review of five staff education records, including those of two nurses, a unit manager, a social worker, and the staff development coordinator, showed no evidence that QAPI training had been completed for any of them. Interviews with these staff members confirmed the lack of QAPI training. One nurse was unfamiliar with the QAPI program and its goals, and stated she had not received any training. The unit manager attended QAPI meetings but could not recall any related education or in-servicing. The social worker reported that her online training and orientation did not include QAPI information. Another nurse also stated he had not received any QAPI training or orientation. The staff development coordinator, who recently attended orientation, did not recall any QAPI training and noted that while there may have been a slide about QAPI in the orientation presentation, she could not recall any details and did not review QAPI with staff during orientation.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. According to federal requirements, a quarterly MDS assessment must have its Assessment Reference Date (ARD) within 92 days of the most recent OBRA assessment, and the assessment must be completed no later than 14 days after the ARD. For five residents, the quarterly MDS assessments were either completed late or not completed at all. Specifically, two residents had their assessments completed 30 days after the ARD, one resident's assessment was completed 26 days late, and two residents' assessments had not been completed as of the date of the survey review. During the survey, the Regional Nurse confirmed that the assessments for these residents were not completed within the required 14-day period following the ARD. The report provides specific admission dates for each resident and details the extent of the delays or lack of completion for each assessment. The deficiency was identified through a review of MDS assessment records and staff interviews, which verified the failure to meet the mandated assessment timelines.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the current date and actual hours worked per shift for RNs, LPNs, and CNAs, was posted as required. On two separate occasions, a surveyor observed that the nurse staffing document displayed in the main lobby was dated two days prior, rather than reflecting the current date. Interviews with the receptionist and scheduler confirmed that the process involved the scheduler preparing the documents and leaving them at the receptionist's desk to be changed out each morning. However, the document was not updated daily as required, resulting in outdated staffing information being posted.
Failure to Follow Up on Psychiatric Recommendations
Penalty
Summary
The facility failed to ensure that nursing staff provided care and services that met professional standards of quality for two residents who required psychiatric interventions and evaluations. For the first resident, who was admitted with diagnoses including Parkinson's Disease and generalized anxiety disorder, a psychiatric consult recommended starting Sertraline for anxiety. However, there was no documentation indicating that the resident's physician was notified of this recommendation, resulting in a lack of timely follow-up. For the second resident, who had diagnoses including dementia and depression, a psychiatric consult recommended adding Citalopram to their medication regimen. The recommendation was not communicated to the physician until 16 days later, during a physician visit, despite the physician agreeing with the recommendation. Interviews with facility staff revealed a breakdown in communication and follow-up procedures, as the Unit Manager and DON were unaware of the unaddressed recommendations, indicating a failure in the facility's process for handling psychiatric recommendations.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary condition, as observed by the surveyor. The walk-in refrigerator had multiple sanitation issues, including black spots on shelving units, brown/green buildup on wheels, and crumb-like buildup in corners. These conditions were observed over several days, and despite the Food Service Director's (FSD) claim that the walk-in was cleaned regularly, the issues persisted. The FSD admitted that kitchen staff had not been documenting their cleaning tasks, and the Regional FSD confirmed that the shelving should be free of black spots and debris. The facility also failed to properly label and date food items in the main kitchen refrigerators. The surveyor found multiple containers of food, including ground food, milk, cottage cheese, and various desserts, that were undated. This lack of proper labeling and dating was observed in both the walk-in and reach-in refrigerators. The FSD and Regional FSD acknowledged that all prepared, plated, and poured food and drink should be labeled and dated, but this was not being consistently done. Additionally, the facility did not ensure proper hand hygiene practices among staff. The surveyor observed issues with handwashing stations, including a broken paper towel dispenser and a lack of hand drying provisions. Staff were seen washing their hands improperly, using washed hands to turn off faucets and touch dispensers, and failing to change gloves after contamination. The FSD and staff confirmed these practices, indicating a lack of adherence to proper hand hygiene protocols.
Failure to Uphold Resident Council Participation and Grievance Resolution
Penalty
Summary
The facility failed to uphold residents' rights to participate in the Resident Council and to have their grievances addressed promptly. The Activity Director (AD) was under the impression that only alert and oriented residents could participate in the Resident Council, which led to selective invitations and exclusion of some residents. This misunderstanding was perpetuated by the previous AD and resulted in several residents being unaware of the Resident Council or not being reminded of upcoming meetings, despite their interest in attending. Additionally, the facility did not have a specific policy for the Resident Council, and grievances raised during these meetings were not documented on grievance forms as required by the facility's grievance policy. The policy stipulated that grievances should be resolved within 3-5 working days, but this was not adhered to. The grievances, such as long call light response times, cold coffee, and laundry issues, were repeatedly brought up in meetings from February to May, yet there was no evidence of timely resolution or follow-up with the residents. Interviews with staff, including the Social Worker and Unit Manager, revealed a lack of proper documentation and follow-up on grievances. The Unit Manager admitted to conducting staff education on call light response but did not perform audits to ensure its effectiveness. The Administrator, who had been in the position for 30 days, had not yet been involved in the grievance process. This lack of coordination and adherence to policy resulted in ongoing resident dissatisfaction and unresolved issues.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of practice for three residents, leading to deficiencies in care. For Resident #216, the facility did not document comprehensive weekly skin assessments. Despite having a stage two pressure injury and Moisture Associated Skin Damage (MASD), the weekly skin observation tools lacked detailed descriptions, including the size and condition of the open areas. Interviews with nursing staff and the Director of Nurses (DON) confirmed that complete skin assessments should include detailed documentation of the wound and surrounding skin, which was not done in this case. Resident #23 did not receive medication as ordered by the physician. The resident was prescribed Debrox Otic Solution to be administered twice daily for five days, but the Medication Administration Record (MAR) indicated that the medication was not given on the first day, resulting in only eight out of ten doses being administered. Interviews with the resident, their daughter, and nursing staff confirmed the medication was not administered as ordered, and there was no documentation to explain the missed doses. For Resident #31, the facility failed to ensure a complete physician's order for Trazodone, an antidepressant. The order was incomplete as it did not specify the strength of the medication. Interviews with nursing staff and the DON revealed that the incomplete order should have been identified during 24-hour order checks, but it was not. This oversight resulted in a lack of clarity regarding the medication's administration.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals, as mandated by their policy and OBRA regulations. Specifically, four residents were not seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter. Resident #17, with severe cognitive impairment and diabetes, had a 143-day gap between physician visits. Resident #18, who is cognitively intact and has congestive heart failure, had a 197-day gap. Resident #31, with severe cognitive impairment and multiple diagnoses including diabetes, had a 174-day gap. Resident #15, with dementia and diabetes, had a 118-day gap. Interviews with the facility's physician and the Director of Nurses revealed that the physician and nurse practitioner were responsible for alternating visits every 90 days for long-term residents and documenting these visits in the electronic medical record. However, the records reviewed did not show evidence of the required physician visits for the residents mentioned. The Director of Nurses confirmed the expectation for residents to be seen every 30 days for the first 90 days after admission and then at least every 60 days, which was not met in these cases.
Failure to Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement, presented to residents as part of the admission packet, was explained in a manner that residents and their representatives could understand. This deficiency was identified during a review of six Arbitration Agreements, where it was found that none of the residents or their representatives were adequately informed about the agreement. Interviews with residents revealed that they were either unfamiliar with the Arbitration Agreement or did not recall it being explained to them. Some residents expressed that they did not understand what arbitration was and were unaware of what they were signing. The Director of Admissions (DOA) stated that she reviews admission documents, including the Arbitration Agreement, with residents within three days of admission. However, she admitted that she does not inform residents that signing the agreement is not a condition of admission, nor does she explain that they are waiving their right to resolve disputes by trial in a court. Additionally, there is no separate document for residents to acknowledge their understanding of the agreement without entering into it. The facility's Administrator, who had been in the position for only 30 days, was not familiar with the process for Arbitration Agreements.
Arbitration Agreement Lacks Neutrality Provisions
Penalty
Summary
The facility failed to ensure that their arbitration agreement included provisions for the selection of a neutral arbitrator and a neutral venue that is convenient for both parties involved. Upon review, the Arbitration Agreement in use did not indicate that residents or their representatives had the right to a neutral arbitrator and venue agreed upon by both parties. During an interview, the Director of Admissions confirmed the absence of such language in the agreement. Subsequently, an updated version of the Arbitration Agreement, effective from May 28, 2024, was provided, which included the necessary provisions for neutrality in arbitrator and venue selection.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's physical status, specifically a significant weight loss, for one resident out of 17 sampled. The facility's policy on weight management requires notifying the physician and family of any significant weight changes, defined as a 5% change in one month, 7.5% in three months, or 10% in six months. Despite this policy, the facility did not notify the physician when the resident experienced a 7.17% weight loss over a short period. The resident, who was admitted with diagnoses including adult failure to thrive, gastric paresis, and lymphedema, showed a weight decrease from 170.2 pounds to 158 pounds within ten days. The facility's records did not show any evidence of physician notification regarding this significant weight loss. Interviews with staff, including a nurse practitioner and the resident's physician, confirmed that they were not made aware of the weight loss until much later, indicating a lapse in communication and documentation. The facility's process for notifying physicians involved leaving notes in a communication binder, which was not effectively utilized in this case. The nurse practitioner and physician both stated they were unaware of the resident's weight loss until it was discussed during a care plan review. The staff development coordinator and unit manager confirmed the lack of documentation and notification, highlighting a failure to adhere to the facility's policies on change of condition and weight management.
Neglect Due to Delayed Call Light Response
Penalty
Summary
The facility failed to ensure timely response to call lights, resulting in neglect of care needs for two residents. Resident #9, diagnosed with Multiple Sclerosis and requiring assistance for personal hygiene, pressed the call light at 8:50 A.M. and was observed by the surveyor at 9:07 A.M. calling out for help. Despite a CNA entering the room at 9:13 A.M. and turning off the call light, the resident did not receive the requested assistance until 9:30 A.M., 40 minutes after the initial call. The resident expressed frustration over the delay and reliance on staff for assistance due to being bed-bound. Similarly, Resident #35, who has hemiplegia and hemiparesis following a stroke, pressed the call light at 8:45 A.M. for assistance with toileting. The surveyor observed the call light still illuminated at 9:13 A.M., and the resident reported soiling themselves due to the delay. A CNA entered the room at 9:33 A.M., 48 minutes after the call light was pressed, to provide the necessary care. The Director of Nursing acknowledged that any staff member should respond to call lights promptly, highlighting a systemic issue in the facility's response to residents' needs.
Inconsistent Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The resident was observed using an oxygen concentrator set to 1.5 liters per minute without a humidifier cup, despite physician's orders indicating the use of humidified oxygen at 2 liters per minute at bedtime and 0-2 liters per minute during the day and evening. The resident's care plan also specified the need for oxygen at 2 liters per minute to maintain oxygen saturation above 90%. The Treatment Administration Record (TAR) indicated that nursing staff signed off on the administration of humidified oxygen at 2 liters per minute, which was inconsistent with the observed practice of providing non-humidified oxygen at 1.5 liters per minute. During an interview, a nurse confirmed the discrepancy between the physician's orders and the actual oxygen administration, acknowledging the need to review and clarify the orders with the physician.
Failure in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure proper communication between the nursing facility and the dialysis center for a resident with end-stage renal disease who required dialysis. The resident, who was cognitively intact, was scheduled for dialysis three times a week. The facility's policy required communication with the dialysis center regarding medication, diet, and lab results, but this was not consistently implemented. The Dialysis Communication Forms, which were supposed to be filled out by the nursing staff, were often incomplete or missing essential information such as the resident's name, time of last meal, medications given, and any problems since the last treatment. On several occasions, the forms were not filled out at all, and there was no indication in the nurses' notes that verbal communication with the dialysis center had occurred. Interviews with nursing staff and the Director of Nursing revealed that the expectation was for the communication forms to be fully completed, but this was not done. The staff acknowledged the oversight, and the Director of Nursing confirmed that the resident took a communication book to dialysis, which should have contained all necessary information. Despite these expectations, the forms remained incomplete, indicating a lapse in the facility's adherence to its own policies and procedures.
Incomplete Medication Order for Trazodone Not Identified
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported an incomplete medication order for Trazodone during the monthly drug regimen review for a resident. The resident, who was admitted in November 2021, had diagnoses including anxiety and depression and was receiving psychotropic medication daily. The Minimum Data Set assessment indicated severe cognitive impairment. The physician's order for Trazodone, dated August 25, 2022, was incomplete as it did not specify the strength of the tablet to be split, which is necessary because Trazodone comes in several strengths. The consultant pharmacist admitted during a telephone interview that he did not identify this error during his monthly medication reviews, which he acknowledged should have been done.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care. For one resident, who was admitted with diagnoses including diabetes mellitus and dependence on renal dialysis, the MDS assessments dated February and May failed to indicate that the resident received dialysis. This oversight was confirmed during interviews with the MDS Nurse and the Regional Nurse, who acknowledged that the MDS should have accurately reflected the resident's dialysis treatment. Another resident, admitted with a diagnosis of diabetes mellitus, was discharged home with medication and services. However, the MDS assessment inaccurately documented the discharge as being to an acute hospital. This error was identified during a review of the resident's medical record, and the MDS Nurse confirmed the need for modification to accurately reflect the discharge status. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate documentation of residents' care and discharge status.
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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