Reservoir Center For Health & Rehabilitation, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Marlborough, Massachusetts.
- Location
- 400 Bolton Street, Marlborough, Massachusetts 01752
- CMS Provider Number
- 225326
- Inspections on file
- 25
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Reservoir Center For Health & Rehabilitation, The during CMS and state inspections, most recent first.
A resident with ESRD missed a hemodialysis session due to transport issues, and the facility failed to notify the physician, breaching policy. Despite the spouse informing staff, there was no documentation or communication to the healthcare provider, as confirmed by interviews with facility staff.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with complex medical needs, including ESRD, COPD, and multiple other conditions. Interviews revealed confusion among staff regarding responsibility for care plan development, leading to non-compliance with facility policy.
A resident with end-stage renal disease missed a dialysis session due to transportation issues, which was not documented or communicated to the physician by the nursing staff. This led to the resident experiencing a change in mental status and requiring emergency dialysis treatment at a hospital. Facility leadership was unaware of the missed session, contrary to expectations.
A resident experienced significant medication errors during admission and re-admission due to incorrect reconciliation of hospital discharge medications. The resident received incorrect dosages of Neurontin and Tacrolimus, contrary to prescribed orders. Facility staff, including nurses and the DON, were unaware of these discrepancies, highlighting a failure in the medication reconciliation process.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, did not provide timely interventions for a resident with C. Diff, and did not ensure safe medication dispensing. Staff on the East One Unit were not required to perform outbreak testing, increasing the risk of COVID-19 transmission. A resident with C. Diff was not provided a commode, leading to shared bathroom use, and staff did not consistently perform proper hand hygiene. Additionally, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, and staff failed to adhere to PPE requirements and properly clean a glucometer machine.
A resident with dementia and malnutrition was not provided a dignified dining experience as a CNA stood over them while assisting with a meal, contrary to the facility's policy. The facility's standards require CNAs to sit at eye level when assisting residents, which was confirmed by the Unit Manager and DON.
The facility failed to notify physicians of treatment changes for two residents, as recommended by specialists. One resident's pressure ulcers were not cleansed with soap and water as advised, and another resident's catheter size change was not communicated to the physician. This lack of communication could delay necessary treatment adjustments.
A resident with a gastrostomy tube and malnutrition was not weighed as required by physician orders and facility policy. Despite a significant change in condition, including weight loss, the resident was not weighed on two occasions. Interviews revealed staff were unaware of the weight measurement schedule, leading to non-compliance with care plan requirements.
The facility failed to review and revise comprehensive care plans for two residents by the interdisciplinary team (IDT). One resident with COPD did not have their care plan reviewed after scheduled assessments due to a canceled and unscheduled IDT meeting. Another resident with Schizoaffective Disorder and Congenital Hydrocephalus did not have their care plan reviewed after re-admission, and expressed a desire to discuss discharge options, which had not been addressed by the facility staff.
A resident with moderate cognitive impairment was not involved in discharge planning discussions, despite expressing a desire to return to the community. The facility failed to conduct an Interdisciplinary Team meeting or document a working discharge plan, leading to a deficiency.
The facility failed to follow physician orders for two residents with indwelling urinary catheters, leading to deficiencies in care. One resident did not receive the correct balloon size or a leg bag as ordered, while another resident's catheter was flushed without proper physician orders or documentation. These actions increased the risk of complications for the residents.
A resident with chronic pain conditions did not receive scheduled pain medications on time, leading to unrelieved pain. The medications, including Acetaminophen, Gabapentin, and Tramadol, were administered 3 to 4 hours late. The resident reported a headache with a pain level of 6 out of 10. The Nurse Practitioner was informed of the missed medications but was not aware they were for pain management.
A resident requiring hemodialysis did not receive meals or medication as scheduled on dialysis days, increasing the risk of malnutrition. The facility failed to coordinate meal and medication times with the dialysis schedule, resulting in missed doses of Sevelamer Carbonate, a medication to control phosphorus levels. Staff interviews revealed a lack of communication between nursing and dietary staff regarding the resident's needs.
A resident with a history of suicidal ideation and PTSD did not receive timely behavioral health services after expressing suicidal thoughts and auditory hallucinations. Despite facility policies requiring immediate psychiatric evaluation, the resident experienced delays in receiving psychiatric and psychological care, with no evidence of services provided until weeks after returning from an inpatient psychiatric stay. Interviews with staff revealed a lack of documentation and adherence to care plans, placing the resident at risk for further psychosocial decline.
A resident with chronic pain did not receive scheduled pain medications on time due to a nurse signing off on the administration without actually giving the medications. The resident, who was cognitively intact and dependent on staff, reported a headache with a pain scale of 6 out of 10 during a medication pass. The facility's policy required timely administration, which was not followed in this instance.
A surveyor and a nurse discovered expired Famotidine tablets in a medication cart, which were not removed as per the facility's medication storage policy. The nurse confirmed that the expired medication should have been taken out and handed to the Unit Manager, instead of being accessible for resident use.
A facility failed to notify the state mental health authority for a resident review after a significant change in mental condition. The resident, admitted with Anxiety Disorder, Depression, and Unspecified Psychosis, was severely cognitively impaired and had not been evaluated by a Level II PASRR. Despite a psychiatric evaluation revealing depression, anxiety, and psychosis, with persistent delusions and hallucinations, the facility did not request a Level II evaluation.
Failure to Notify Physician of Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician of a missed hemodialysis session, which is a critical treatment for individuals with End Stage Renal Disease (ESRD). The resident, who was dependent on hemodialysis three times a week, missed a scheduled session due to transportation issues. Despite the resident's spouse informing the nursing staff of the missed session upon their return to the facility, there was no documentation in the medical record to indicate that the physician was notified of this significant event. Interviews with facility staff, including the Evening Nurse Supervisor, Nurse Practitioner, and the Director of Nurses, revealed that none were aware of the missed dialysis session or that the physician had not been informed. The facility's policy requires that any change in a resident's condition, such as a missed medical treatment, be communicated to the resident's healthcare provider. The failure to notify the physician of the missed dialysis session represents a breach of this policy and a deficiency in the facility's duty to ensure proper medical oversight and continuity of care for the resident.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented within 48 hours of admission for two residents. Resident #1, admitted in September 2024, had multiple complex medical conditions including End Stage Renal Disease requiring hemodialysis, a history of heart transplant, chronic anemia, diabetes mellitus, and multiple pressure injuries. Despite these significant health issues, there was no documentation of baseline or comprehensive care plans addressing these needs within the required timeframe. Similarly, Resident #2, admitted in October 2024, had conditions such as urinary tract infection, acute on chronic respiratory distress, COPD, malnutrition, and urinary retention with an indwelling catheter. Again, there was no evidence of care plans developed within 48 hours to address these immediate care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development of baseline care plans. The Evening Supervisor admitted to only addressing fall risk and activities of daily living in care plans upon admission, while the Assistant Director of Nurses indicated that the Unit Manager is typically responsible for developing these plans. The Director of Nurses confirmed that it is the nurses' responsibility to initiate and complete baseline care plans, with management conducting chart audits to ensure compliance. Despite these expectations, the facility did not meet its policy requirements, resulting in the deficiency.
Failure to Ensure Dialysis Care Due to Missed Session
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required hemodialysis three times a week. The resident missed a dialysis session due to a transportation issue, as the transportation company was unable to assist in getting the resident out of the car. The resident's family member informed the facility's nursing staff that the dialysis treatment was missed, but there was no documentation in the resident's medical record to indicate that the physician was notified of the missed session. Subsequently, the resident experienced a change in mental status and was found unresponsive, leading to an emergency transfer to the hospital. The hospital's emergency department report indicated the resident had an altered mental status, was hypoxic, and required emergent dialysis treatment due to elevated potassium levels. Interviews with the nurse practitioner, physician, and nursing leadership revealed that none were aware of the missed dialysis session, and the facility's expectation was that the nursing staff should have informed the resident's physician of the missed session.
Medication Reconciliation Errors in Resident Admission and Re-admission
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during both admission and re-admission processes. Upon admission, the resident, who had a history of end-stage renal disease, heart transplant, chronic anemia, and diabetes mellitus, was prescribed Neurontin to be taken three times a week on dialysis days. However, the facility's physician's orders incorrectly instructed the administration of Neurontin three times a day, every day, resulting in the resident receiving nine doses instead of the prescribed one dose over a period of several days. Additionally, the resident was prescribed Nitroglycerin ointment to be applied twice daily as a scheduled dose, but it was administered as needed, contrary to the hospital discharge summary. Upon re-admission, the resident's medication reconciliation process failed again, leading to a duplicate order for Tacrolimus, which was administered at twice the prescribed dosage. The facility's staff, including the nurses and the Director of Nursing, were unaware of these discrepancies, and the medication reconciliation form indicated no issues had been identified. The facility's policy required two licensed nurses to complete and sign the medication reconciliation, but this process was not effectively implemented, resulting in significant medication errors for the resident.
Infection Control and Medication Dispensing Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures on the East One Unit during a COVID-19 outbreak. Staff on this unit were not required to perform outbreak testing, contrary to the facility's policy and Massachusetts Department of Public Health guidelines, which mandate testing of exposed staff and residents every 48 hours until no new cases are identified for seven days. The Infection Preventionist admitted to not realizing that staff on the affected unit were required to perform outbreak testing, which increased the risk of COVID-19 transmission. The facility also failed to implement timely and effective interventions to prevent the transmission of Clostridium Difficile (C. Diff) for a resident actively being treated for the infection. The resident, who was frequently incontinent of bowel, was not provided with a commode upon returning from the hospital, resulting in the use of a shared bathroom with other residents. Additionally, staff did not consistently perform hand hygiene with soap and water after exiting the resident's room, as required for C. Diff precautions. The lack of paper towels in the shared bathroom further hindered proper hand hygiene practices. Furthermore, the facility did not ensure that medications were dispensed in a safe and sanitary manner. During a medication pass, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, potentially contaminating the medication. Additionally, staff failed to adhere to PPE requirements for Droplet Precautions, as observed when a CNA entered a room without wearing the necessary eye protection. The facility also did not properly clean and disinfect a glucometer machine after use, increasing the risk of infection transmission.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with dementia and malnutrition. The resident, who was moderately cognitively impaired, was observed lying in bed with the head elevated during a breakfast meal. A Certified Nurses Aide (CNA) was seen standing over the resident while assisting with the meal, which is contrary to the facility's policy. The facility's CNA Standard of Care Information Sheet, updated in March 2023, specifies that each resident should be treated with dignity and respect, and that CNAs should sit at eye level when assisting residents with meals. During an interview, the Unit Manager confirmed that the CNA should have been seated next to the resident. The Director of Nursing also stated that CNAs are trained to sit while assisting residents with meals, as per the facility's standards.
Failure to Notify Physicians of Treatment Changes
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner (NP) of necessary changes in treatment for two residents, based on recommendations from specialist medical practitioners. For one resident, the facility did not inform the Physician/NP of a recommended change in treatment from a Wound Care Consultant. The resident had two Stage Four pressure ulcers, and the Wound Care Specialist recommended cleansing the ulcers with soap and water instead of normal saline to reduce bacterial load and promote healing. However, the facility continued using normal saline, and there was no evidence that the Physician/NP was notified of this recommendation. In another case, the facility failed to notify the Physician of a change in treatment for a resident following a Urology consultation. The resident had a change in the size of their indwelling urinary catheter, as recommended by the Urologist. Despite this change, there was no documentation indicating that the Physician was informed, and the resident's treatment plan was not updated accordingly. The facility's policy requires informing the resident's healthcare provider of any changes in condition, but this was not adhered to in this instance. These deficiencies highlight a lack of communication between the facility staff and the residents' healthcare providers, which could potentially delay necessary treatment adjustments. The facility's failure to notify the appropriate medical personnel of specialist recommendations for treatment changes increased the risk of complications for the residents involved.
Failure to Implement Weight Monitoring for Resident with G-tube
Penalty
Summary
The facility failed to implement the care plan for a resident who was readmitted with a gastrostomy tube and a diagnosis of malnutrition. The facility's policy required weight measurements to be obtained and documented upon admission, re-admission, monthly, or significant change in condition. Despite this, the resident was not weighed on two occasions as ordered by the physician, specifically on 9/20/24 and 9/27/24. This oversight occurred even though the resident had experienced a significant change in condition, including weight loss and a new pressure ulcer. Interviews with facility staff revealed a lack of awareness and adherence to the weight measurement schedule. A Certified Nurse Aide (CNA) responsible for the resident's care was unsure of the frequency of required weight measurements, and a nurse confirmed that the resident had not been weighed as ordered. The facility's weight record corroborated the absence of weight measurements for the specified dates, indicating a failure to follow the physician's orders and the facility's own policy.
Failure to Review and Revise Care Plans by IDT
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for two residents. Resident #40, who was admitted with Chronic Obstructive Pulmonary Disease (COPD), had a comprehensive review assessment completed on 5/24/24 and a quarterly review assessment on 8/17/24. However, there was no evidence that the comprehensive care plan was reviewed and revised by the IDT following these assessments. The Social Worker (SW) indicated that an IDT meeting was scheduled but not rescheduled after being canceled, and another meeting was never scheduled. Resident #9, admitted with Schizoaffective Disorder and Congenital Hydrocephalus, had a comprehensive MDS assessment completed on 7/8/24. The resident was transferred to the hospital on the same day and returned to the facility later. The care plans were initiated on 7/8/24, but there was no evidence of the plan of care being reviewed with the resident after re-admission. The resident expressed a desire to explore discharge options but had not discussed this with the facility staff. The SW confirmed that there was no evidence of the resident's participation in care plan meetings or discussions about the plan of care.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to a deficiency. The facility's policy required an Interdisciplinary Team (IDT) meeting within two to three business days of admission to address discharge planning, involving the resident and relevant staff members. However, for the resident in question, there was no evidence that such a meeting occurred or that the resident was involved in discussions about discharge planning. The resident, who was moderately cognitively impaired, expressed a desire to return to the community with support services. Despite this, the facility did not engage the resident in discharge planning discussions or assess their needs for community services. The resident's plan of care was revised to remain in the facility without documented reasons, and there was no evidence of a working discharge plan or communication with the resident's previous group home. Interviews with the Social Worker and Director of Nursing revealed that the resident had previously lived in a group home and had supportive family involvement. However, the facility did not document any evaluation for discharge planning or discussions with the resident about their goals. The lack of documentation and involvement of the resident in discharge planning led to the deficiency identified by the surveyors.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents with indwelling urinary catheters, increasing their risk for complications. For one resident, the staff did not follow physician orders to insert the Foley catheter with the correct balloon size and failed to switch the catheter bag from straight drainage to a leg bag when the resident got out of bed in the morning. The resident, who was cognitively intact, reported that the staff had not offered a leg bag, and a nurse confirmed that the balloon size was incorrect and that the leg bag was not provided as ordered. For another resident, the facility staff did not obtain a physician order that included indications, type, and amount of solution required to flush and irrigate the resident's indwelling urinary catheter. The resident's treatment administration record showed that the catheter was flushed on two occasions without documentation of the indications or procedure used. The staff development coordinator confirmed that a physician order was necessary for catheter flushing, including specific instructions, which were not present in this case. The facility's policy on urinary catheterization required physician orders for catheter placement and irrigation, which were not adhered to in these instances. The staff's failure to follow these orders and document the necessary information for catheter care led to deficiencies in the care provided to these residents, as observed and reported by the surveyors.
Untimely Administration of Pain Medications
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, resulting in unrelieved pain due to the untimely administration of physician-ordered pain medications. The resident, who was admitted with conditions including Paralytic Syndrome, Chronic Pain, and Diabetic Neuropathy, was cognitively intact and dependent on staff for activities of daily living. The resident's medication regimen included Acetaminophen, Gabapentin, and Tramadol, which were scheduled to be administered at specific times throughout the day. However, on the day of the incident, these medications were not administered as scheduled during the morning medication pass. Nurse #1 signed off on the administration of the medications but admitted during an interview that they had not been given at the scheduled times, resulting in a delay of 3 to 4 hours. The resident reported experiencing a headache with a pain level of 6 out of 10 on the numeric pain scale. The Nurse Practitioner was informed of the missed medications but was not initially aware that they were the resident's pain medications. The resident had previously agreed with the Nurse Practitioner to take the medications on schedule to avoid unrelieved pain, as they were particular about not receiving opioid medications.
Failure to Coordinate Dialysis Care and Nutrition
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring hemodialysis, specifically in coordinating meal and medication times with the dialysis treatment schedule. The resident, who was admitted with conditions including end-stage renal disease and moderate protein-calorie malnutrition, was not offered breakfast or food to take on dialysis days. This oversight increased the resident's risk for malnutrition and weight loss, as meals were not provided before leaving for dialysis, nor was food taken to the dialysis center. Additionally, the facility did not administer a dialysis support medication, Sevelamer Carbonate, as scheduled and with food as required. The medication, intended to control serum phosphorus levels, was supposed to be given three times a day with meals. However, the resident missed doses on several occasions, and the medication was not administered at the correct times, particularly on dialysis days when the resident was not present for the scheduled administration. Interviews with staff revealed a lack of communication and coordination between nursing and dietary staff regarding the resident's meal and medication needs on dialysis days. The Food Service Director indicated that meals were prepared but not delivered to the resident due to a lack of notification from nursing staff. The Director of Nursing acknowledged that the medication should have been administered with meals and that the resident's meal schedule should have been adjusted to accommodate dialysis treatment days.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident with a known history of suicidal ideation and post-traumatic stress disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, PTSD, major depression, and suicidal ideation, expressed suicidal thoughts and auditory hallucinations shortly after admission. Despite the facility's policy requiring immediate psychiatric evaluation or emergency room referral if psychiatric services were unavailable, the resident did not receive timely psychiatric care. The resident was placed on one-to-one supervision and was eventually sent for emergency psychiatric evaluation due to the unavailability of psychiatric services within the facility. After returning from an inpatient psychiatric stay, the resident continued to express suicidal ideation and depressive symptoms. However, there was a significant delay in providing psychiatric and psychological services, as the resident was not seen by behavioral health services until several weeks after returning to the facility. Interviews with facility staff, including the social worker, unit manager, and director of nursing, revealed a lack of documentation and evidence of timely psychiatric follow-up and one-to-one supportive therapy as outlined in the resident's care plan. The facility's failure to adhere to its policies and provide necessary behavioral health services placed the resident at risk for further psychosocial decline.
Medication Administration Error for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of pain medications. The resident, who was cognitively intact and dependent on staff for activities of daily living, had a history of chronic pain and neuropathic pain, requiring scheduled pain medications. On a particular day, Nurse #1 signed off on the administration of Acetaminophen, Tramadol, and Gabapentin as given, although these medications had not been administered to the resident at the scheduled times. This was observed during a medication pass when the resident reported a headache with a pain scale of 6 out of 10, and Nurse #1 administered Tramadol at that time. The facility's policy required medications to be administered safely and timely, within an hour before or after the scheduled time. However, Nurse #1 did not adhere to this policy, as she had not administered the 8:00 A.M. Acetaminophen, the 9:00 A.M. Tramadol, and the 8:00 A.M. Gabapentin medications by the time of the surveyor's observation. The Director of Nursing confirmed that it was not the facility's practice to sign off medications as given when they were not administered, indicating a breach in the facility's medication administration policy.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not removing expired medications from a medication cart. During an observation by a surveyor and a nurse, 13 individually packaged Famotidine tablets with an expiration date of 9/23 were found in the top drawer of a medication cart on the second floor nursing unit. The nurse acknowledged that the expired medication should not have been in the cart and should have been removed and given to the Unit Manager, rather than being available for administration to residents.
Failure to Notify State Mental Health Authority After Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one resident. Specifically, the facility did not request a Preadmission Screening and Resident Review Level II screen (PASRR) after the resident received a diagnosis of Psychosis and experienced limitations in major life activities due to mental illness. The resident was admitted with diagnoses of Anxiety Disorder, Depression, and Unspecified Psychosis, and was severely cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Despite these conditions, the resident had not been evaluated by a Level II PASRR. The initial PASRR Level I screen, completed prior to admission, indicated no diagnosis of mental illness or treatment history for mental illness in the past two years, and no limitations in major life activities due to mental illness. However, a psychiatric evaluation conducted later revealed the resident experienced depression, anxiety, and psychosis, with staff reporting persistent delusions and hallucinations. The evaluation recommended increasing antipsychotic medication and initiating an antidepressant. The social worker, who was new to the facility, acknowledged that a Level II evaluation should have been requested following the diagnosis of Psychosis, but it had not been done.
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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