Regalcare At Worcester
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 25 Oriol Drive, Worcester, Massachusetts 01605
- CMS Provider Number
- 225467
- Inspections on file
- 22
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regalcare At Worcester during CMS and state inspections, most recent first.
A resident with end stage renal disease, diabetes, and a Stage IV sacral pressure injury did not receive the physician-ordered Collagenase wound care upon admission. Instead, nursing staff provided only normal saline and a dry protective dressing, failing to follow the hospital discharge orders and facility protocol. This lapse was due to staff not referencing the discharge summary and assuming the correct care was in place.
A resident dependent on hemodialysis missed a scheduled treatment due to transportation and communication failures between facility staff and the dialysis center. The resident went four days without dialysis, and when finally transported for treatment, was found to be unstable and required hospital transfer. The deficiency was caused by delayed physician orders, unclear responsibility for arranging transportation, and lack of adherence to facility policy.
The facility did not ensure privacy for residents during Resident Council meetings, as staff frequently used the designated meeting space as a passageway, interrupting the sessions. Multiple residents and the Activities Director confirmed that privacy was not consistently maintained, with staff entering the area during meetings despite residents' wishes for confidentiality.
Surveyors found that two units had multiple resident rooms and common areas with environmental deficiencies, including damaged walls, exposed wiring, broken fixtures, and missing outlet covers. Maintenance logs showed no documented requests for these repairs, and residents reported ongoing frustration with unresolved issues. The facility had no quality improvement project in place to address these environmental concerns prior to the survey.
Surveyors observed multiple residents smoking outside of designated areas, such as on sidewalks and driveways, and discarding cigarette butts on the ground instead of in covered receptacles. Staff supervising the smoking areas did not intervene or direct residents to use the proper disposal containers. The facility lacked clear signage to indicate designated smoking areas, and cigarette refuse was found scattered around the property, contrary to facility policy.
A resident with a gastrostomy tube did not have the total amount of enteral formula administered documented as ordered by the physician, and weekly weight monitoring was not performed as recommended. The resident experienced significant weight loss over a one-month period, and the facility's records did not show compliance with required monitoring and documentation practices.
A nurse mixed a resident's prescribed oral medications into a cup of coffee and left it with a CNA, instructing the CNA to ensure the resident consumed it, rather than remaining present to observe administration as required by policy. The resident, who was severely cognitively impaired and unable to self-administer medications, consumed the coffee without the nurse present, and the CNA confirmed the nurse did not return to supervise. Facility leadership acknowledged that only licensed nurses should administer medications and that staff must remain with residents during administration.
A resident with dementia and muscle weakness, who was cognitively intact and experiencing oral pain, did not receive timely follow-up dental care after a recommended appointment was canceled and not rescheduled. Documentation indicated the need for extractions and a deep cleaning, but the facility failed to ensure the resident saw a dentist as required by policy.
Staff did not follow Enhanced Barrier Precautions by failing to wear gowns, as required, while providing high contact care to a resident with an indwelling urinary catheter. Despite clear signage and available PPE, CNAs only wore gloves during care activities such as transferring, and one CNA was unsure of the signage's meaning. Nursing and infection control staff confirmed that both gowns and gloves were required for this resident.
A resident with multiple chronic conditions and a documented need for corrective lenses was not accurately coded on the MDS assessment as using eyeglasses. Despite an optometry evaluation and direct observation of eyeglasses in the resident's room, the MDS indicated no use of corrective lenses. Interviews confirmed the resident wore glasses, and staff later acknowledged the coding error.
Failure to Implement Physician-Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident with a Stage IV sacral pressure injury received appropriate and adequate wound care as ordered by the physician upon admission. The hospital discharge summary specified daily application of Collagenase ointment for the wound, but this order was not transcribed or implemented by nursing staff. Instead, the resident received only normal saline wash and a dry protective dressing (DPD) for several days following admission. Nursing staff did not reference the hospital discharge summary when obtaining wound care orders, and the physician assumed the hospital's wound care orders were being followed. The Director of Nursing confirmed that the facility's protocol was to follow hospital discharge wound care orders until the wound nurse practitioner could assess the resident, but this did not occur. The resident had significant medical conditions, including end stage renal disease requiring dialysis, diabetes mellitus, and a Stage IV sacral pressure injury. Documentation showed that the wound was present and measured upon admission, but the prescribed treatment was not provided. The failure to implement the correct wound care orders resulted from a lack of communication and adherence to protocol by nursing staff, as well as an assumption by the physician that the appropriate care was being given.
Failure to Ensure Timely Dialysis Due to Transportation and Communication Errors
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD), who required hemodialysis three times a week, missed a scheduled dialysis session due to a transportation issue and miscommunication between the facility and the dialysis center. The resident was admitted with orders to continue dialysis on specific days, but the nursing staff did not obtain the physician's order for dialysis and transportation until several days after admission. As a result, the resident went four days without receiving dialysis, and attempts to reschedule the missed session were unsuccessful due to lack of available openings at the dialysis center. The resident was transported to the dialysis center on a day when no appointment was scheduled, resulting in a return to the facility without treatment. The lack of clear responsibility for booking transportation, with confusion between nursing staff and the resident's family, contributed to the missed treatment. When the resident finally arrived for the next scheduled dialysis session, they were found to be unstable, confused, and lethargic, necessitating transfer to the hospital emergency department. The facility's own policy required nursing staff to arrange transportation and ensure care according to recognized standards, which was not followed in this case.
Failure to Provide Privacy During Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate privacy for residents during Resident Council meetings, as required by resident rights policies. Specifically, the meeting space reserved for these gatherings was not private, with staff frequently using the area as a passageway to access other parts of the building during the meetings. This lack of privacy was confirmed by 10 out of 15 residents in attendance, who reported that staff regularly cut through the space while meetings were in progress. The Resident Council President also noted that privacy during meetings was uncommon, indicating this was the first time in a long period that the group had experienced a private session. The Activities Director, responsible for organizing Resident Council meetings, acknowledged that in the previous year, meetings had been interrupted by staff walking through the hallway approximately four times. The Director further stated that staff should not have been present during these meetings, as residents desired privacy, which had not been consistently respected. The meeting space itself was observed to be divided by a hallway with double doors at each end, but this arrangement did not prevent staff from passing through during council meetings.
Failure to Maintain Safe and Homelike Environment in Resident Units
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment on two out of four resident units. On Unit 2, eight out of 22 resident rooms and the activity room were found with issues such as gouges in the walls, nonfunctional or missing nightlight covers, holes and scrapes in doors and walls, clogged sinks, dented heating vents, and exposed wiring. On Unit 4, all 19 resident rooms had similar deficiencies, including gouges and holes in walls, torn wallpaper, missing or exposed electrical outlet covers, missing floor tiles, and holes from door handles. These environmental issues were directly observed by surveyors during their walkthroughs. Interviews with the Unit Manager revealed that maintenance issues are supposed to be documented in a log book accessible to all staff, and the Maintenance Director is expected to review these logs during daily rounds. However, a review of the maintenance log books for the affected units showed no documented requests for repairs related to the observed deficiencies in the past 90 days. The Maintenance Director confirmed awareness of some issues but indicated that materials needed to be ordered for repairs. Despite the process in place for reporting and addressing maintenance concerns, the lack of documentation and follow-up resulted in ongoing environmental problems. During a Resident Council Group interview, the majority of residents expressed ongoing frustration with the facility environment, citing persistent issues such as holes in walls, broken heating vents, and bathrooms needing repairs. Residents reported that these problems had not been addressed despite being present for some time. The facility administration acknowledged that renovation and remodeling projects were only partially complete and that there had been no quality improvement project focused on environmental repairs for the affected units prior to the survey.
Failure to Maintain Safe and Sanitary Smoking Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary smoking environment for residents, staff, and visitors by not ensuring that proper signage was visible to designate resident smoking areas, not ensuring residents were smoking only in designated areas, and not ensuring safe disposal of cigarette materials. Observations by surveyors revealed that multiple residents were smoking on facility sidewalks and driveways, as well as in the circular driveway and covered porch near the main entrance, rather than in clearly designated smoking areas. Cigarette butts and related trash were found scattered on the ground, in landscaped areas, and around shrubbery and mulch, rather than being disposed of in the provided covered receptacles. Several residents were observed discarding cigarettes on the ground, and staff supervising the smoking areas did not intervene or direct residents to use the appropriate receptacles. Interviews with the Administrator confirmed that the facility considered both the covered porch and sidewalk areas as designated smoking areas, but there was a lack of clear signage to indicate this. The Administrator acknowledged that residents should be using the cigarette receptacles and that staff should be directing them accordingly, but stated that the area was difficult to keep clean due to frequent resident smoking. The facility's policy required safe smoking practices, use of designated areas, and proper disposal of cigarette materials, but these procedures were not consistently followed or enforced.
Failure to Document Enteral Feeding and Monitor Weights for Tube-Fed Resident
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident with a gastrostomy tube. Specifically, the facility did not document the total amount of enteral formula administered during the day shift as ordered by the physician. The resident was prescribed a specific enteral feeding regimen, including Jevity 1.2 cal at a set rate and volume, with instructions to record the total amount infused each day. However, review of the Medication Administration Record (MAR) for March and April did not show any documentation of the total enteral formula administered, as required by the physician's order. Additionally, the facility did not perform weekly weight monitoring for the resident as recommended by the dietician and outlined in facility policy. The resident, who was admitted with diagnoses including traumatic brain injury, acute respiratory failure, dysphagia, and gastrostomy status, experienced a significant weight loss of 11.1% over a one-month period. The weight record showed that weekly weights were not obtained for four weeks as required for residents at high nutritional risk, and this was confirmed by the dietician during an interview.
Medications Left Unattended and Administered by Unauthorized Staff
Penalty
Summary
A deficiency occurred when a nurse failed to ensure the secure and proper administration of medications to a resident with severe cognitive impairment. The nurse prepared the resident's medications by mixing them into a cup of coffee and then handed the cup to a certified nurse aide (CNA), instructing the CNA to ensure the resident consumed the coffee containing the medications. The nurse then left the dining room, leaving the medications unattended with the CNA and the resident, rather than remaining present to directly observe the administration as required by facility policy. The resident involved had a history of dementia, major depressive disorder, anxiety disorder, gastroesophageal reflux disease, and unspecified blepharitis, and was assessed as severely cognitively impaired. The resident's care plan included orders for multiple oral medications, some of which were to be crushed and could be mixed with fluids. Facility policy required that staff remain with residents until all medications are taken, especially for those unable to self-administer, and that only licensed nurses administer medications. Observations and interviews confirmed that the nurse did not stay with the resident during medication administration and left the responsibility to a CNA, who is not authorized to administer medications. The nurse was not in direct line of sight when the resident consumed the coffee containing the medications, and the CNA confirmed that the nurse did not return to supervise or remove the cup. The Assistant Director of Nursing acknowledged that the nurse should have remained with the resident to ensure proper administration and that CNAs are not permitted to administer medications.
Failure to Provide Timely Dental Follow-Up
Penalty
Summary
The facility failed to provide routine dental services for one resident by not scheduling a follow-up dental appointment in a timely manner. The resident, who was cognitively intact and had a history of dementia and muscle weakness, had an activated healthcare proxy and signed consent for dental services. Documentation showed that the resident required extractions and a deep cleaning, and needed to see a dentist for a treatment plan for decay. Despite these recommendations, a dental appointment was canceled and not rescheduled, resulting in a delay in dental care. Interviews confirmed that the resident experienced ongoing oral pain and had not seen the dentist for an extended period. The unit manager acknowledged that the dental care recommendations were not followed up on as required, and that the missed appointment should have been rescheduled. The facility's policy required assistance with dental appointments and timely follow-up, which was not provided in this case.
Failure to Follow Enhanced Barrier Precautions During High Contact Care
Penalty
Summary
Facility staff failed to adhere to infection control standards by not following Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to facility policy, EBP requires staff to wear gowns and gloves during high contact care activities for residents with indwelling medical devices, such as catheters, to reduce the transmission of multidrug-resistant organisms (MDROs). The policy and signage outside the resident's room clearly indicated the need for gown and glove use during activities like dressing, bathing, transferring, and device care. On the observed date, two certified nurse aides (CNAs) donned gloves but did not wear gowns while providing high contact care, including transferring the resident with a mechanical lift. The signage indicating EBP requirements was present and visible outside the room, and a storage bin with appropriate PPE was available. Despite these measures, the CNAs entered the room and performed care without the required gowns. One CNA later stated she was unsure of the meaning of the signage or to which resident it applied. Interviews with nursing and infection control staff confirmed that the resident was on EBP due to the presence of an indwelling catheter and that staff should have worn both gowns and gloves during care. The involved CNA had completed orientation and received education on hand hygiene, PPE donning, and EBP prior to the incident. The resident was cognitively intact, aware of their catheter, and reported occasional leakage. The failure to follow EBP was directly observed and acknowledged by facility leadership.
Failure to Accurately Code Corrective Lens Use on MDS Assessment
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for one resident, resulting in an omission regarding the use of corrective lenses. Record review showed that the resident was admitted with multiple diagnoses, including chronic systolic heart failure, chronic kidney disease, type 2 diabetes mellitus, and cerebrovascular disease. An optometry evaluation documented that the resident had cataracts and had been dispensed glasses. However, the MDS assessment indicated that the resident did not use corrective lenses, despite evidence to the contrary. During interviews, the resident confirmed wearing eyeglasses, and the surveyor observed two pairs of eyeglasses on the resident's nightstand. The Corporate MDS Nurse initially was unaware of the resident's use of eyeglasses but later acknowledged that the resident did wear them and that the MDS had been coded incorrectly. The failure to accurately code the use of corrective lenses was identified through record review, resident interview, and staff interview.
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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