Renaissance Manor On Cabot
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 279 Cabot Street, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225352
- Inspections on file
- 19
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Renaissance Manor On Cabot during CMS and state inspections, most recent first.
A resident, who required assistance with toileting, was denied help by a CNA and instructed to use a bed pan or urinate in bed, leading to feelings of humiliation. The incident was witnessed by the resident's roommate, and an internal investigation confirmed the CNA's failure to treat the resident with dignity and respect. Other residents also reported similar rough behavior by the CNA.
The facility did not conduct annual performance evaluations for four CNAs, as required by policy. Employee records showed no evaluations for CNAs hired on various dates, and it was confirmed that the DON had not completed any reviews since March 2020. This oversight places residents at risk for unevaluated care delivery.
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required by their policy. The Infection Preventionist (IP), responsible for monitoring antibiotic use, admitted to not performing any tracking since assuming the role. The IP was unable to provide evidence of monitoring or line listing for the past year, indicating a lapse in the facility's ASP. This failure placed residents at risk for complications related to antibiotic usage, as it is crucial to ensure residents receive the correct medication and avoid unnecessary antibiotics.
A resident with multiple health conditions did not receive physician-ordered lab work and a psychiatric consult following Medication Regimen Reviews. Despite recommendations and orders, the facility failed to complete necessary tests and evaluations, revealing a breakdown in the process for addressing pharmacist recommendations.
The facility failed to maintain adequate staffing levels, leading to delayed care for residents. Multiple instances of insufficient licensed nurse and CNA coverage were observed, resulting in long wait times for assistance with ADLs and call light responses. Residents and staff reported challenges due to the facility's layout and staffing shortages, despite administration's belief that staffing was sufficient.
A resident with Multiple Sclerosis and chronic pain syndrome received Tramadol outside the prescribed parameters for moderate to severe pain. The facility's policy required defined parameters for PRN medications, but the MARs showed Tramadol was administered when the pain score was 0 or 3. Interviews revealed the resident sometimes requested Tramadol to aid sleep, which was acknowledged as poor practice due to dependency risks.
The facility failed to provide timely Medicare coverage termination notices to three residents. A resident did not receive the NOMNC two days before benefits ended, and another resident did not receive the SNF ABN, which would have informed them of potential financial responsibility. Additionally, a third resident did not receive the NOMNC despite having a discharge plan. The MDS Nurse acknowledged these oversights.
A facility failed to develop a care plan for monitoring a resident's use of psychotropic medications, specifically Trazodone and Mirtazapine, despite the resident's diagnoses of Altered Mental Status and Dementia. The MDS Nurse confirmed the absence of a care plan and physician's order for monitoring potential side effects and response, which should have been in place.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall, but the facility failed to update the resident's Fall Care Plan with new interventions. Despite the facility's policy requiring investigation and intervention after accidents, the investigation lacked documentation of a root cause or new interventions. The resident's representative expressed concerns about the lack of detailed information and the resident being left unattended for extended periods.
A resident admitted with multiple wounds did not receive a timely skin and wound assessment as required by facility policy. The admitting nurse failed to remove existing dressings and document the resident's skin condition, resulting in a lack of wound measurements and care orders. Observations showed unchanged dressings dated before admission, and wound care was only initiated after surveyor intervention, revealing untreated wounds.
A resident with a history of pressure ulcers and dependent on supplemental oxygen experienced discomfort and skin breakdown on the ears due to nasal cannula use. Despite complaints, the facility failed to implement adequate monitoring and interventions, leading to an open area on the resident's ear. Nursing staff did not promptly assess the skin condition or use appropriate protective measures, resulting in a deficiency in pressure ulcer prevention.
A facility failed to monitor a resident's weight as ordered, despite the resident's risk for malnutrition and history of weight loss. The resident, with severe protein-calorie malnutrition, dysphagia, and dementia, experienced significant weight changes that were not addressed timely. The RD identified a significant weight gain and requested a re-weigh, but no re-weight was documented. Interviews revealed a lack of follow-through on re-weigh requests, and the facility did not provide evidence of obtaining or attempting a re-weight.
A resident with chronic respiratory failure and pneumonia did not receive oxygen therapy as prescribed, with the flow rate set below the ordered 4-6 LPM range. Observations showed the nasal cannula improperly applied, and documentation lacked evidence of the flow rate during oxygen saturation checks, hindering effective monitoring.
A facility failed to obtain informed consent for bed rail use for a resident with cognitive impairment and mobility issues. Despite the resident's consent form indicating that bed rails should not be used, surveyors observed the rails in the up position without a physician's order or care plan documentation. The ADON confirmed the oversight, acknowledging the lack of informed consent and proper documentation.
The facility failed to ensure timely review and response to Medication Regimen Reviews (MRR) for two residents. One resident's MRR regarding Seroquel use was not documented or addressed by the physician until a month later. Another resident's MRR was not found in the clinical record, and no physician response was documented. The facility's policy required MRR findings to be communicated, documented, and acted upon within 30 days, which was not followed.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a Certified Nurse Aide (CNA) refused to assist the resident with toileting needs. The incident occurred when the resident, who was cognitively intact and required substantial assistance with toileting due to frequent incontinence, used the call light to request help to walk to the bathroom. The CNA denied the request, instructing the resident to use a bed pan or urinate in the bed, which left the resident feeling humiliated and distraught. The resident's roommate, who was also cognitively intact, witnessed the incident and corroborated the resident's account. The facility's internal investigation confirmed that the CNA did not treat the resident in a dignified and respectful manner. The social worker's interviews with other residents on the CNA's assignment revealed additional complaints about the CNA's rough and tough behavior during care. The facility's administrator acknowledged the outcome of the investigation, which supported the resident's claim of being treated without dignity and respect.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for four Certified Nurses Aides (CNAs), which is a requirement to ensure the competency and performance of duty. The facility's policy, revised on 7/1/22, mandates that managers meet with employees at least annually for performance reviews. However, a review of employee records revealed that CNAs hired on various dates, including 7/9/21, 7/6/90, 5/9/23, and 4/30/21, did not have performance evaluations documented for the past 12 months. During an interview, Nurse Consultant #1 confirmed that the Director of Nursing (DON), who was on leave, had not completed performance reviews for any CNA staff since March 2020. Each department head, including the DON, is responsible for completing these evaluations annually on the employees' 12-month anniversary dates.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required by their policy. The policy, last revised on 10/24/22, mandates the implementation of antibiotic use protocols and systems for monitoring antibiotic use, with core elements including leadership, accountability, drug expertise, action, tracking, reporting, and education. The Infection Preventionist (IP) is tasked with monitoring and supporting the ASP through rounds, reviewing provider orders, medical record documentation, and available reports. However, the IP admitted during an interview that since assuming the role on 8/9/24, he had not performed any antibiotic monitoring or tracking, which was previously the responsibility of the Director of Nursing (DON) who was on medical leave. The IP was unable to provide evidence of antibiotic monitoring or line listing for the past year, indicating a lapse in the facility's ASP. This failure to track antibiotic use placed residents at risk for complications related to antibiotic usage, as it is crucial to ensure residents receive the correct medication, improve with prescribed treatment, and avoid unnecessary antibiotics. The lack of monitoring and tracking highlights a significant deficiency in the facility's adherence to its own ASP policy, potentially compromising resident safety and care quality.
Failure to Complete Physician-Ordered Lab Work and Consults
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Summary
The facility failed to adhere to professional standards of practice concerning the transcription of physician orders for a resident, leading to a deficiency in the management of the resident's medication regimen. The resident, who had multiple diagnoses including Type 2 Diabetes, Severe Protein-Calorie Malnutrition, Dementia with Anxiety, and Bipolar Disorder, was subject to several Medication Regimen Reviews (MRRs) conducted by a Consultant Pharmacist. These reviews resulted in recommendations for laboratory tests and a psychiatric consult, which were not completed as ordered by the physician. The MRRs conducted on various dates recommended specific lab work, including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and A1c tests, to monitor the resident's diabetes and medication side effects. Despite the physician addressing these recommendations and providing written orders, the facility failed to obtain the required lab work on multiple occasions. Additionally, a psychiatric consult to evaluate the need for a gradual dose reduction of psychotropic medications was recommended but not completed. Interviews with facility staff, including the Consultant Nurse and Unit Manager, revealed that the process for addressing the Consultant Pharmacist's MRRs was ineffective, as they were unable to provide evidence that the ordered lab work and psychiatric consult were completed. This deficiency highlights a breakdown in the facility's process for ensuring that physician orders and pharmacist recommendations are acted upon and documented in the resident's medical record.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to maintain sufficient nursing staffing levels to meet the needs of its residents, as evidenced by multiple instances of inadequate staffing between September 1, 2024, and October 6, 2024. The facility's staffing schedules did not align with the staffing needs identified in their own assessment, resulting in numerous shifts without the required number of licensed nurses and CNAs. This deficiency was observed across various dates, with specific instances where no licensed nurse was scheduled for certain shifts, and CNA staffing was below the required ratio for the resident census. Residents and their representatives reported significant delays in receiving care, particularly in response to call lights and assistance with activities of daily living (ADLs). During a Resident Council meeting, residents expressed concerns about long wait times for call light responses and assistance with toileting needs. Specific cases included a resident with multiple sclerosis who experienced anxiety due to delayed assistance for toileting, and another resident who waited 15 minutes for help to use a commode, expressing frustration over the delay. Staff interviews revealed that the facility's layout and staffing levels made it challenging to provide timely care. CNAs and nurses reported being overworked, with some shifts having only one CNA per unit, making it difficult to meet residents' needs. Despite these concerns, the facility administration and consultant nurse believed the staffing levels were adequate, based on per patient day calculations and resident acuity. However, the observed deficiencies in staffing and care delivery indicate a disconnect between the facility's assessment and the actual staffing needs.
Unnecessary Administration of Tramadol for Pain Management
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of Tramadol. The resident, who was admitted with diagnoses including Multiple Sclerosis and chronic pain syndrome, had a care plan that included medication for pain management. The physician's orders specified that Tramadol should be administered for moderate to severe pain, defined as a pain score of 4-10 on the Numeric Rating Scale. However, the medication was administered on multiple occasions when the resident's pain score was recorded as 0 or 3, which is outside the prescribed parameters. The facility's policy on pain management required that PRN medications have defined parameters for use and that their effectiveness and side effects be documented. Despite this, the MARs from July to September 2024 showed that Tramadol was given without adherence to these guidelines, and no PRN Acetaminophen was administered on those days. Interviews with the resident and a nurse revealed that the resident sometimes requested Tramadol to aid sleep, which the nurse acknowledged was not good practice due to the risk of dependency. This indicates a failure to follow the physician's orders and the facility's pain management policy, leading to the unnecessary administration of medication.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notices regarding Medicare coverage termination and potential financial liability for three residents. Resident #81 did not receive the Notice of Medicare Non-Coverage (NOMNC) two days prior to the termination of Medicare benefits, as required. The NOMNC was signed by the resident's representative on the day after the benefits ended, indicating a failure to provide timely notice. The Minimum Data Set (MDS) Nurse acknowledged the oversight and noted that there was no evidence of a prior telephone conversation or certified mail to ensure the notice was received in advance. Resident #82 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) when their Medicare benefits ended, which would have informed them of their financial responsibility if they chose to continue receiving services. The MDS Nurse admitted that the SNF ABN should have been provided but was not. Similarly, Resident #27 did not receive a NOMNC two days before their Medicare-covered services ended, despite having a discharge plan in place. The MDS Nurse confirmed the oversight, acknowledging that the notice should have been issued in advance.
Failure to Develop Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to develop a care plan for monitoring the use of psychotropic medications for a resident, specifically concerning the antidepressant medications Trazodone and Mirtazapine. The resident, who was admitted with diagnoses of Altered Mental Status and Dementia, had moderate cognitive impairment and was receiving these medications. Despite the presence of physician's orders for these medications, there was no documented evidence of a care plan addressing the monitoring of potential side effects and the resident's response to these medications. During an interview, the MDS Nurse confirmed that there should have been a care plan in place for monitoring the psychotropic medications, as it is standard practice to enter an order in the physician's orders for such monitoring. The nurse acknowledged that the clinical record lacked both a physician's order and a care plan for the psychotropic medication monitoring, which was an oversight in the resident's care management.
Failure to Update Fall Interventions After Resident's Fall
Penalty
Summary
The facility failed to review and revise fall interventions for a resident after an unwitnessed fall, which was identified during a survey. The resident, who had severe cognitive impairment, Parkinsonism, Atrial Fibrillation, Dementia, unsteadiness on feet, and repeated falls, experienced a fall on 7/16/24. Despite the fall, the facility did not update the resident's Fall Care Plan with new interventions to prevent future falls. The facility's policy required that accidents be reported, reviewed, and investigated, with appropriate interventions implemented based on the investigation's conclusions. However, the investigation into the resident's fall did not document a root cause, witness statements, or any new interventions added to the care plan. The resident's Fall Care Plan, initiated in October 2022 and last revised in May 2023, included several interventions such as ambulation assistance, verbal cues for safety, and maintaining a clutter-free environment. Despite these measures, the resident continued to experience falls, and the care plan was not updated following the fall on 7/16/24. Interviews with facility staff, including the Corporate Clinical Specialist and the Assistant Director of Nursing (ADON), revealed that interventions should have been added to the care plan after the fall investigation. However, no additional information or interventions were provided to the survey team by the time of the survey exit. The resident's representative expressed concerns about the multiple falls and the lack of detailed information provided by the facility staff. Observations during the survey noted that the resident was often left unattended for several hours, and the facility staff did not consistently check in with the resident. The facility's failure to update the care plan and implement new interventions after the fall represents a deficiency in ensuring the safety and well-being of the resident.
Failure to Conduct Timely Wound Assessment and Care
Penalty
Summary
The facility failed to assess and provide appropriate wound care for a resident upon admission, which was not in accordance with professional standards of practice. The resident was admitted with multiple wounds, including bilateral leg wounds and cellulitis, as documented in the hospital discharge summary. However, the facility did not perform a comprehensive skin and wound assessment upon the resident's admission, leading to a delay in wound management. The facility's policy required a licensed nurse to perform and document a skin inspection on all newly admitted residents, including removing any existing dressings to assess the skin condition. This procedure was not followed for the resident, as the admitting nurse did not remove the dressings or document the skin assessment. Consequently, the resident's wounds were not measured, and no wound care orders were obtained, which was confirmed by multiple staff members, including the Assistant Director of Nursing and the Unit Manager. Observations by the surveyor revealed that the resident's dressings were dated prior to admission and had not been changed. It was only after the surveyor raised concerns that the facility staff, including Nurse #1, conducted an initial wound care assessment. This assessment revealed multiple wounds with varying conditions, including necrosis and maceration, which had not been previously documented or treated according to the discharge instructions from the hospital.
Failure to Prevent Pressure Ulcers from Nasal Cannula Use
Penalty
Summary
The facility failed to adhere to professional standards of practice in preventing and managing pressure ulcers for a resident who was dependent on supplemental oxygen. The resident, who had a history of pressure ulcers and was at risk for developing new ones, complained of discomfort and pain caused by the nasal cannula used for oxygen delivery. Despite these complaints, the facility did not implement adequate monitoring and interventions to prevent the development of a pressure ulcer on the resident's upper ears. Observations and interviews revealed that the resident frequently removed the nasal cannula due to discomfort, and the tubing was often found under the resident's chin instead of over the ears. The resident's ears were observed to be red and had an open area on the back of the right ear, indicating skin breakdown. Certified Nurses Aides (CNAs) reported the resident's complaints to the nurses, but the issue was not adequately addressed, and the resident continued to experience discomfort and skin irritation. The facility's policy required regular skin assessments and monitoring for changes, but these were not effectively carried out. The nursing staff failed to assess the resident's skin condition promptly and did not implement appropriate interventions to alleviate the discomfort and prevent further skin breakdown. The use of gauze and tape on the oxygen tubing was an inadequate measure, and the facility did not utilize more suitable protective measures until after the deficiency was identified.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's weight, which was crucial due to the resident's risk for malnutrition and history of weight loss. The resident, who was admitted with severe protein-calorie malnutrition, dysphagia, and dementia, was supposed to have their weight monitored monthly as per physician's orders. However, the facility did not identify a significant weight change in a timely manner, did not obtain a re-weight when a significant weight change was identified by the Registered Dietitian (RD), and failed to obtain a monthly weight as ordered by the physician. The resident's weight records showed fluctuations, with a significant weight gain noted by the RD, who requested a re-weigh. Despite this, no re-weight was documented after the initial weight gain was identified. Interviews with staff revealed that the process for obtaining and recording weights involved CNAs and nurses, but there was a lack of follow-through on re-weigh requests. The facility did not provide evidence that a re-weight was obtained or attempted, leading to concerns from the resident's representative about the resident's weight loss and the assistance provided during meals.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident receiving supplemental oxygen therapy. The deficiency was identified for a resident who was admitted with chronic respiratory failure with hypoxia and pneumonia, requiring continuous oxygen therapy. The physician's orders specified that the resident should receive oxygen at a flow rate of 4-6 liters per minute (LPM) via nasal cannula continuously, with regular monitoring of oxygen saturation levels and other vital signs. Observations by the surveyor revealed that the resident's oxygen was not administered according to the physician's orders. On multiple occasions, the oxygen concentrator was set at a flow rate of 2.5 LPM, which was below the prescribed range. Additionally, the nasal cannula was not properly applied, as it was observed under the resident's chin instead of in the nose. The resident expressed discomfort with the nasal cannula, stating it hurt their ears, which may have contributed to improper application. The facility's documentation practices were also found lacking, as there was no evidence of the oxygen flow rate being documented at the time oxygen saturation levels were measured. This omission made it difficult to assess the resident's tolerance to oxygen therapy. The nurse confirmed that the flow rate should have been documented to ensure compliance with the physician's orders and to monitor the resident's response to the therapy effectively.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for a resident, identified as Resident #7, which is a violation of their policy. The resident was admitted with diagnoses including altered mental status, abnormal gait and mobility, falls, and urinary retention. Despite the facility's policy requiring informed consent and a physician's order for bed rail use, the resident's consent form indicated that bed rails were not to be used. However, observations by the surveyor on multiple occasions revealed that the bed rails were in the up position, contrary to the consent form and without a physician's order or care plan documentation. The facility's policy mandates a bed rail evaluation and informed consent from the resident or their representative before bed rails are used. The Assistant Director of Nursing (ADON) confirmed that informed consent should have been obtained and that the use of bed rails should be included in the resident's care plan. However, the clinical record lacked evidence of an assessment or informed consent for the use of bed rails for Resident #7. The ADON acknowledged the oversight, noting that the consent form dated March 15, 2024, indicated that bed rails should not be used, yet they were observed in use without proper documentation or consent.
Failure to Address Medication Regimen Reviews Timely
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) conducted by the Consultant Pharmacist was reviewed and addressed in a timely manner for two residents. For one resident, the MRR completed by the Consultant Pharmacist on September 4, 2024, regarding the use of Seroquel, an antipsychotic medication, was not documented in the clinical record nor addressed by the physician. The resident, who was cognitively intact and had no behaviors, was receiving Seroquel for depression, but there was no documented evidence of the Consultant Pharmacist's recommendation or any response by the facility until October 7, 2024. For another resident, the MRR completed by the Consultant Pharmacist on September 11, 2024, was not found in the clinical record, and there was no evidence of a response from the physician. This resident had multiple diagnoses, including Type 2 Diabetes, Severe Protein-Calorie Malnutrition, Dementia with Anxiety, and Bipolar Disorder. The Consultant Nurse indicated that the MRRs were emailed to the Director of Nursing (DON), who was responsible for addressing them with the provider and filing them in the resident's clinical record. However, the MRR dated September 11, 2024, was not located or provided to the survey team before the survey exit. The facility's policy required that MRR findings be communicated to the DON or designee and the Medical Director, documented, and filed with other Consultant Pharmacist recommendations in the residents' chart. Recommendations should be acted upon within 30 calendar days, with physician intervention documented in the resident's medical record. The failure to adhere to these procedures resulted in the deficiency noted by the surveyors.
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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