Rehabilitation & Nursing Center At Everett (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Massachusetts.
- Location
- 289 Elm Street, Everett, Massachusetts 02149
- CMS Provider Number
- 225300
- Inspections on file
- 18
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Rehabilitation & Nursing Center At Everett (the) during CMS and state inspections, most recent first.
The facility's infection prevention and control program was found deficient due to inadequate tracking, monitoring, and analysis of infections. The Infection Preventionist did not track clinical signs or trends, relying on antibiotic prescriptions as infection indicators. The Director of Nurses expected adherence to infection control guidelines, but these were not followed.
The facility failed to implement an effective Antibiotic Stewardship Program, as the Infection Preventionist (IP) did not track clinical signs, symptoms, or infection trends, and did not obtain lab reports on antibiotic use. The Director of Nurses (DON) expected proper documentation and implementation of the program, including tracking and evaluating antibiotic use and infections, but the IP's actions did not meet these expectations.
A facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, with diagnoses including foot drop and peripheral vascular disease, was prescribed Mirtazapine and Fluoxetine for depression. Despite receiving these medications daily, the Unit Manager and DON confirmed the absence of required consents, which should have been obtained on admission and annually.
The facility failed to notify the Physician or NP of recommendations made by a Wound Physician and a Psychiatric NP for two residents. One resident with severe cognitive impairment and unhealed pressure ulcers did not receive updated wound care treatments, while another resident with bipolar disorder did not have their medication dosage adjusted as recommended. These lapses occurred due to a lack of communication from the nursing staff to the attending providers.
The facility failed to accurately code MDS assessments for two residents. One resident's eating abilities were incorrectly documented as 'not applicable,' despite requiring supervision due to aspiration risks. Another resident was discharged to the hospital without a completed discharge MDS assessment, which was acknowledged as an oversight by the MDS nurse.
A nurse failed to follow professional standards by leaving a cup of MiraLAX with a resident without ensuring its consumption, contrary to facility policy. The nurse acknowledged the mistake, and the DON confirmed that medications should not be left unattended.
A resident with severe cognitive impairment and esophageal issues was not adequately supervised during meals, despite care plan requirements for supervision and cueing. Observations showed staff leaving the resident alone during meals, contrary to the care plan. Interviews with staff confirmed the discrepancy between required and provided care.
A resident with severe cognitive impairment was found with a bruise on the right forearm, which was not documented or reported by staff. Despite the facility's policy requiring prompt reporting of skin changes, the bruise was only noted during a survey, and previous assessments inaccurately indicated intact skin.
A resident at high risk for pressure ulcers did not have a care plan developed, and a physician's order for Prevalon boots was not implemented. Despite assessments indicating high risk, the facility failed to create a person-centered care plan. Observations showed the resident was not wearing the prescribed boots, and staff interviews confirmed the lack of documentation and awareness of the order.
A resident receiving oxygen therapy in an LTC facility was found to have an oxygen concentrator without an air filter during two separate observations. The facility's policy requires weekly maintenance of the filter, which was not adhered to, as confirmed by staff interviews. The resident, admitted with respiratory conditions, was cognitively intact and had physician orders for weekly filter changes.
A nurse in an LTC facility made two medication errors, resulting in a five percent error rate. A resident received incorrect dosages of Vitamin D3 and calcium due to the nurse substituting medications without a physician's order. The DON confirmed that such substitutions should not occur without proper authorization.
The facility failed to secure medication storage areas properly, with an unlocked and unsupervised medication cart and medication room observed on separate units. Staff interviews confirmed that these areas should be locked unless attended by a nurse.
A resident with dementia and other health issues was not provided dental services upon admission, despite losing dentures prior to arrival and requesting new ones. The facility's policy required dental services to be offered and referrals made within three days if dentures were lost, but the resident was not seen by a dentist, and no consent or declination form was on file. Interviews with staff confirmed the oversight.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of systematic tracking, monitoring, and analysis of infections. The facility's policy outlined a comprehensive surveillance protocol, including data collection from various sources such as clinical records and microbiology reports, and the calculation of infection rates. However, the facility's infection control program did not adhere to these guidelines. The QAPI Antibiotics form for May indicated a diagnosis of C. diff, but lacked details on infection control measures. Additionally, the infection control program's line listings did not show evidence of monitoring or analyzing infections. During an interview, the Infection Preventionist (IP) admitted to not tracking clinical signs, symptoms, or trends of infections, relying instead on the prescription of antibiotics as an indicator of infections. The IP did not obtain lab reports on antibiotic use or calculate monthly infection control rates, and was unable to provide documentation of infection control surveillance. The Director of Nurses (DON) expressed expectations for the facility to follow infection control guidelines, track and evaluate infections, and document surveillance of communicable diseases, but these practices were not being followed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in January 2024, outlined the responsibilities of the Infection Preventionist (IP) in tracking antibiotic use, monitoring adherence to prescribing standards, and reviewing antibiotic resistance patterns. However, the facility's Antibiotic Use Monthly Tracking Forms lacked the necessary detailed information to monitor appropriate antibiotic use. During an interview, the IP admitted to not tracking clinical signs, symptoms, or infection trends, and not obtaining lab reports on antibiotic use, relying instead on the number of antibiotics prescribed as an indicator of infections. The Director of Nurses (DON) expressed expectations for the facility to document and implement the antibiotic stewardship program, including tracking, evaluating, and reporting antibiotic use and infections. The DON expected cultures and labs to be reviewed, and evaluations to be discussed regarding the continuation or cessation of antibiotics. However, the IP's failure to track and evaluate infections and antibiotic use, as well as the lack of detailed tracking forms, contributed to the deficiency in the facility's antibiotic stewardship efforts.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, admitted in July 2024, had diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease. The resident's Minimum Data Set indicated a severe cognitive impairment with a score of 3 out of 15 on the Brief Interview for Mental Status. The resident was prescribed Mirtazapine and Fluoxetine for depression, as per physician orders dated 7/19/24 and 7/23/24, respectively. The August 2024 Medication Administration Record confirmed the resident received these medications daily. However, during an interview, the Unit Manager acknowledged the absence of psychotropic consents for these medications, which was confirmed by the Director of Nurses, who stated that consents should be obtained on admission and annually.
Failure to Communicate Physician Recommendations
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of recommendations made by a Wound Physician for two residents. Resident #141, who was admitted with diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease, had severe cognitive impairment and unhealed pressure ulcers. The Wound Physician recommended specific dressing treatments for the resident's wounds on two occasions, but these recommendations were not communicated to the Physician or Nurse Practitioner. As a result, the resident continued to receive the previous treatment plan, which did not align with the Wound Physician's updated recommendations. Similarly, for Resident #53, who was readmitted with diagnoses including bipolar disorder, dysphagia, and sleep apnea, the facility failed to communicate new medication recommendations made by a Psychiatric Nurse Practitioner. Despite the resident expressing feelings of increased depression, the recommendation to increase the dosage of Lamictal was not relayed to the attending Nurse Practitioner. Consequently, the resident continued to receive the previous dosage, as the nursing staff did not update the Nurse Practitioner about the new recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, the MDS did not accurately reflect their functional abilities for self-care, specifically eating. Despite being observed eating with supervision due to aspiration risks, the MDS inaccurately documented their eating abilities as 'not applicable.' Interviews with staff revealed a lack of awareness regarding the incorrect documentation, indicating a failure in accurately assessing and recording the resident's needs. Another resident was discharged to the hospital and did not return to the facility, yet the facility failed to complete a discharge MDS assessment. The resident's medical record only contained a quarterly MDS assessment, and the discharge assessment was overlooked. The MDS nurse acknowledged the oversight during an interview, admitting that the discharge assessment was forgotten. This oversight highlights a lapse in the facility's process for ensuring complete and accurate documentation of resident discharges.
Failure to Ensure Medications Are Not Left Unattended
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that nursing staff did not leave medications unattended with a resident. During a medication pass, a nurse prepared and administered medication, including MiraLAX mixed in water, to a resident. However, the nurse left the cup of MiraLAX with the resident and did not wait to confirm that the resident consumed the entire amount. This action was contrary to the facility's policy, which mandates that medications should not be left unattended and that nurses must observe residents to ensure medication consumption. Interviews with the nurse involved and the Director of Nursing confirmed the deviation from the facility's policy. The nurse acknowledged that she should have waited until the resident took all the medications, and the Director of Nursing reiterated that nurses are required to stay with residents until all medications are taken and should not leave medications with residents.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with severe cognitive impairment and a history of esophageal issues. The resident, who was admitted with diagnoses including dementia, bipolar disorder, and Barrett's esophagus, was observed on multiple occasions eating without the required supervision. The facility's policy and the resident's care plan clearly indicated the need for supervision and cueing during meals due to cognitive impairment and the risk of aspiration. Observations by the surveyor revealed that staff consistently left the resident alone during meal times, despite the care plan's directive for close supervision. On several occasions, staff set up the meal tray and exited the room, leaving the resident to eat without any oversight. This lack of supervision was contrary to the care plan, which specified that the resident required supervision to monitor for aspiration and to provide verbal cueing. Interviews with facility staff, including a CNA, a nurse, and the Director of Rehabilitation, confirmed the discrepancy between the care plan requirements and the actual care provided. The CNA believed the resident only needed setup assistance, while the nurse and the Director of Rehabilitation acknowledged the need for supervision. The Director of Rehabilitation agreed with the surveyor's observations that the resident was not receiving the necessary supervision during meals, which was a clear deficiency in the care provided by the facility.
Failure to Identify and Document Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident, resulting in the failure to identify a skin injury on the resident's right forearm. The resident, who has severe cognitive impairment due to dementia, was observed with a round discoloration with yellowed edges on the right forearm, consistent with a bruise. Despite the presence of this bruise, the facility's progress notes from 7/30/24 to 8/26/24 did not document any skin discoloration, and a weekly skin assessment inaccurately indicated the resident's skin as intact. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care did not report the skin change, and the nurse confirmed that the bruise appeared to be a few days old. The Assistant Director of Nursing (ADON) acknowledged that the bruise was not reported until it was brought to her attention by the nurse. The facility's policy requires that any skin changes or injuries be promptly reported and documented, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to develop a care plan for a resident at high risk for developing pressure ulcers and did not implement a physician's order for heel protection. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, type 2 diabetes, and a partial traumatic amputation, was assessed multiple times as being at high risk for pressure ulcers. Despite this, the facility did not create a person-centered care plan with individualized goals and interventions to address this risk. Interviews with staff confirmed that a care plan should have been developed for the resident's risk of pressure ulcers. Additionally, the facility did not follow a physician's order for the resident to wear Prevalon boots while in bed. Observations and interviews revealed that the resident was not wearing the boots, and they were not present in the room. Staff interviews indicated a lack of awareness and documentation regarding the use of the boots, which were intended as a preventative measure for the resident's heel condition. The Assistant Director of Nursing acknowledged the oversight, noting that the boots were meant to be documented on the Treatment Administration Record.
Oxygen Concentrator Filter Missing for Resident
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident who required oxygen therapy. The deficiency was identified when the oxygen concentrator used by the resident did not have an air filter in place during observations on two separate occasions. The facility's policy on oxygen therapy, dated January 3, 2024, mandates that filters should be washed weekly and dried thoroughly before being reinstalled. However, the absence of the air filter was noted during observations on August 26 and August 27, 2024. The resident involved was admitted to the facility in July 2024 with diagnoses including sepsis, pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The physician's orders required the oxygen tubing and filter to be changed weekly, yet the air filter was missing during the surveyor's observations. Interviews with the Unit Manager and the Director of Nurses confirmed that the air filter should have been in place to prevent infection risks.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and interviews conducted during a survey. One nurse was observed making two medication errors out of 40 opportunities, resulting in a five percent error rate. These errors affected one resident, who received incorrect dosages of Vitamin D3 and calcium. Specifically, the resident was administered 5000 units of Vitamin D3 and calcium with 400 units of vitamin D, instead of the prescribed 1000 units of cholecalciferol and 600 milligrams of calcium carbonate. During an interview, the nurse admitted to substituting medications with what was available on hand, leading to the resident receiving an excess of 4400 units of vitamin D. The Director of Nursing confirmed that nurses should not substitute medications without a physician's order and that the correct procedure would be to contact the physician for an appropriate substitute if the prescribed medication is unavailable.
Medication Storage Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with accepted professional standards of practice. Specifically, the medication cart on one of the units was observed to be unlocked and unsupervised at two different times on the same day. During interviews, both the Unit Manager and the Director of Nurses confirmed that the medication cart should be locked if a nurse is not present at it. Additionally, the medication room on another unit was found to be unlocked and unsupervised on two consecutive days. No staff were present in the medication room or at the nurses' station during these times. Interviews with a nurse and the Unit Manager confirmed that the medication room should always be locked unless a nurse is present in the room. The Director of Nurses also stated that she expects the medication rooms to be locked unless a nurse is present.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with multiple diagnoses, including dementia, dysphagia, and diabetes mellitus. The resident, who had intact cognition, reported losing dentures prior to admission and had been requesting new dentures since then. Despite the facility's policy requiring dental services to be offered upon admission and referrals to be made within three days if dentures are lost, there was no record of the resident being offered dental services or having a signed consent or declination form on file. The resident had not been seen by a dentist since admission, and the clinical record lacked documentation of any oral evaluation. Interviews with the Unit Manager and the Director of Nurses confirmed that the resident should have been offered dental services upon admission and should have been seen by a dentist to replace the lost dentures. The Unit Manager acknowledged that the resident had not received an oral evaluation and was not added to the list for dental evaluation, despite physician orders and nutritional recommendations indicating the need for such services. The Director of Nurses also confirmed that the resident should have been seen by a dentist for a follow-up to obtain new dentures.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
