Riverbend Of South Natick
Inspection history, citations, penalties and survey trends for this long-term care facility in S Natick, Massachusetts.
- Location
- 34 South Lincoln Street, S Natick, Massachusetts 01760
- CMS Provider Number
- 225615
- Inspections on file
- 15
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Riverbend Of South Natick during CMS and state inspections, most recent first.
A resident with dementia and other health issues experienced significant weight loss, but the facility failed to notify the Physician or NP in a timely manner. Despite the Registered Dietician identifying the weight loss, the NP was only informed after a recommendation to add Ensure supplements. The Physician's notes did not address the weight loss, indicating a lapse in communication and intervention.
A resident with Alzheimer's and breast cancer was found with their bed positioned against the wall, potentially acting as a restraint. The facility did not conduct an assessment or have a care plan for this setup, as confirmed by staff interviews. The bed's position was due to limited room space, but no documentation supported this decision.
A facility failed to refer a resident for a PASRR Level II evaluation despite documented diagnoses of Depression and Unspecified Psychosis. The resident's hospital records indicated a history of Mood Disorder-Depression and prescriptions for antipsychotic medications. The PASRR Level I screen inaccurately showed no mental illness, leading to a missed Level II evaluation. The Social Worker admitted the screen was incorrect, acknowledging the need for further evaluation.
The facility failed to update care plans for three residents, leading to deficiencies in their care. A resident's incontinence care plan was not revised to reflect the current catheter size. Another resident's fall care plan lacked new interventions after a fall incident. Additionally, a resident and their representative were not invited to care plan meetings, as confirmed by the social worker responsible for the process.
A resident with dementia, dysphagia, anemia, and celiac disease experienced significant weight loss, but the facility failed to notify the RD and NP in a timely manner. The RD's recommendation for lab work was not implemented, and there was a delay in addressing the resident's nutritional needs. Interviews revealed communication lapses and non-adherence to the weight assessment process.
The facility did not provide the required RN coverage for at least eight consecutive hours on two Saturdays, with no RN or DON available to oversee resident care, placing residents at risk.
A nurse in an LTC facility committed multiple medication errors, resulting in a 16% error rate. Errors included incorrect dosing of Vitamin D3 and Vitamin B12, failure to ensure complete administration of MiraLAX, and improper blood pressure measurement before administering Metoprolol. The nurse also neglected to encourage a resident to rinse their mouth after using an inhaler, contrary to facility policy.
A resident with hypertension, heart failure, and coronary artery disease was administered Metoprolol without the required blood pressure and heart rate checks. Despite facility policy requiring vital sign verification before medication administration, a nurse failed to perform these checks, leading to a significant medication error.
A nurse failed to perform hand hygiene during medication administration for two residents, one with a history of stroke, anxiety, depression, and diabetes, and another with hypertension, heart failure, coronary artery disease, and depression. The nurse did not wash or sanitize hands before and after administering medications, including eye drops, and used a single tissue for both eyes of a resident.
The facility failed to offer Pneumococcal Vaccinations to three residents over 65, despite their eligibility for updated doses. The medical records for these residents did not indicate that they were offered, received, or declined the vaccinations upon admission. The Director of Nursing acknowledged the oversight.
A facility failed to accurately code MDS assessments for a resident receiving Hospice services. The resident, with Alzheimer's and breast cancer, was on Hospice since September, but assessments in December and March did not reflect this. The MDS Coordinator, responsible for coding, acknowledged the error.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of a significant change in condition for a resident who experienced a notable weight loss. The resident, who was admitted with diagnoses including dementia, dysphagia, anemia, and celiac disease, showed a weight decrease from 156.4 lbs to 140 lbs between March and April 2024, which was a 10.49% change. Despite the Registered Dietician identifying this significant weight loss, the facility staff did not inform the Physician or NP in a timely manner, preventing potential alterations in treatment. The facility's policy on weight assessment and intervention outlines specific thresholds for significant weight loss, which were exceeded in this case. However, the medical record review revealed that the NP was not made aware of the weight loss until the Dietician recommended adding Ensure supplements on April 24, 2024. The Physician's progress notes also failed to address the resident's weight loss or nutritional status during this period, indicating a lapse in communication and intervention regarding the resident's nutritional risk.
Failure to Assess Bed Position as Potential Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from potential physical restraints, as observed by surveyors. The deficiency involved a resident with Alzheimer's Disease and Intraductal Carcinoma of the breast, who was found with the right side of their bed positioned flush against the wall. This arrangement potentially restricted the resident's ability to exit the bed freely, which could be considered a form of restraint. The facility's policy on restraints emphasizes that restraints should only be used for medical symptoms and not for convenience or discipline, and any restraint must be assessed and documented. The surveyor's observations revealed that there was no physician's order, assessment, or care plan regarding the bed's positioning against the wall. Interviews with the Unit Manager and a Certified Nurses Aide confirmed that no assessment had been conducted to determine if the bed's position acted as a restraint. The CNA mentioned that the bed was placed against the wall due to limited space in the room, and the resident preferred to be in bed with the head elevated. However, the lack of documentation and assessment for this setup was a clear oversight by the facility.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II evaluation, which is required for individuals with a positive Level I screen for mental illness, intellectual disability, or related conditions. The resident in question was admitted with diagnoses of Depression and Unspecified Psychosis, and the hospital documentation indicated a history of Mood Disorder-Depression, prescriptions for Sertraline, and recommendations for antipsychotic medications Seroquel and Haldol. Despite this, the PASRR Level I Screening Form inaccurately indicated that the resident did not have a documented diagnosis of a mental illness or mental disorder, resulting in a negative Level I screen. The facility's policy requires the Director of Social Services to initiate the pre-admission screen process upon receiving a referral. However, the Social Worker responsible for reviewing the hospital documentation and completing the PASRR Level I screen acknowledged that the screen was not accurate and that a Level II evaluation was necessary. This oversight occurred despite the resident's documented history of mental illness and the need for specialized services, as indicated by the hospital's referral form and the facility's initial nurse practitioner visit note.
Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For one resident, the incontinence care plan was not updated to reflect the current size of the suprapubic catheter, despite changes in the physician's orders. This oversight was confirmed during observations and interviews with the unit manager and the director of nursing, who acknowledged that the care plan should have been revised to include the correct catheter size. Another resident experienced a fall, but the facility did not update the fall care plan to include new interventions to prevent future falls. The resident had a history of falls and severe cognitive impairment, yet the incident report for the fall was not reviewed by the interdisciplinary team, and no new interventions were added to the care plan. This lack of action was confirmed during interviews with the director of nursing, who stated that the incident had not been reviewed as required. Additionally, the facility failed to ensure that a resident and/or their representative were invited to participate in care plan conference meetings. The resident, who had severe cognitive impairment, was unsure if they had attended any care plan meetings. The care plan conference summary notes did not document the resident's or their representative's attendance or invitation to the meetings. The social worker responsible for the care plan conference process confirmed that there was no documentation indicating that the resident or their representative had been invited or had declined to attend the meetings.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address the nutritional needs of a resident who experienced significant weight loss. The resident, who was admitted with diagnoses including dementia, dysphagia, anemia, and celiac disease, experienced a weight loss of greater than 10% over six months. The facility did not notify the Registered Dietitian (RD) or the Physician/Nurse Practitioner (NP) in a timely manner when the weight loss was identified. Additionally, the facility did not implement the RD's recommendation to obtain lab work to assess the resident's nutritional status. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the RD should be notified immediately. However, the RD was not informed of the resident's weight loss on 4/9/24 and only discovered it during a routine review of the weight report. The RD recommended obtaining lab work and initiating a nutritional supplement, but there was no documentation that these recommendations were followed. The NP was not notified of the weight loss until 4/24/24, resulting in a delay in addressing the resident's nutritional needs. Interviews with facility staff revealed a lack of communication and adherence to the weight assessment process. The RD relied on nursing staff to communicate dietary recommendations to the NP or MD, but this did not occur. The NP stated that she was not informed of the weight loss until the recommendation for a nutritional supplement was made. The Unit Manager and Director of Nursing acknowledged that the process for weight assessment was not followed, and there was no evidence of multidisciplinary meetings to address the resident's weight loss.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Specifically, there was no evidence of RN coverage on two specific Saturdays, 5/4/24 and 5/11/24, and no nurse staff waivers were in place for these dates. Additionally, there was no Director of Nursing (DON) available to serve as a charge nurse during these times. This lack of RN coverage placed all residents at risk of not having their clinical needs met, either directly by an RN or indirectly by the Licensed Practical Nurses (LPNs) or Certified Nurses' Aides (CNAs) under the RN's supervision. Interviews with the facility's Scheduler, DON, and Administrator confirmed the absence of RN coverage on the specified dates.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by Nurse #1 committing four errors out of 25 opportunities, resulting in a 16% error rate. For Resident #9, Nurse #1 administered an incorrect dose of Cholecalciferol, providing only one tablet instead of the prescribed two. Additionally, Nurse #1 did not ensure that Resident #9 consumed the entire dose of MiraLAX, as the powder settled at the bottom of the cup and was left on the table. For Resident #4, Nurse #1 did not accurately check the resident's blood pressure and heart rate before administering Metoprolol, as required by the physician's orders. The nurse attempted to measure blood pressure without a stethoscope and documented an incorrect reading. Furthermore, Nurse #1 administered an incorrect dose of Vitamin B12, giving 100 mcg instead of the ordered 500 mcg. The nurse also failed to encourage the resident to rinse their mouth after using an inhaler, which is necessary to prevent fungal infections. The facility's policy on medication administration, which includes verifying vital signs and ensuring the correct dosage and method of administration, was not followed. Interviews with the Director of Nursing and Unit Manager confirmed these errors and acknowledged the discrepancies in medication administration for both residents. These actions and inactions led to the identified deficiencies in medication management.
Failure to Assess Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was not properly assessed before medication administration. The resident, who had a medical history of hypertension, heart failure, and coronary artery disease, was prescribed Metoprolol, a medication used to control blood pressure. According to the physician's orders, the medication was to be withheld if the resident's systolic blood pressure was less than 100 or if the heart rate was less than 50. However, during a medication pass, Nurse #1 administered Metoprolol without obtaining the required blood pressure and heart rate measurements. The facility's policy on administering medications, revised in 2012, mandates that vital signs must be checked if necessary before administering medications. Despite this policy, the surveyor observed that Nurse #1 did not measure the resident's blood pressure or heart rate before giving the Metoprolol. This oversight was confirmed during interviews with the Unit Manager and the Director of Nursing, who acknowledged that the nurse should have obtained the necessary measurements prior to administering the medication.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control standards during the medication administration process, as observed by surveyors. Nurse #1 did not perform appropriate hand hygiene before and after administering medications to two residents. Specifically, during the administration of medications to Resident #9, Nurse #1 neglected to wash or sanitize her hands before and after the process. Similarly, while administering eye drops to Resident #4, Nurse #1 failed to perform hand hygiene both before and after the procedure. Additionally, Nurse #1 used a single tissue to wipe both of Resident #4's eyes after instilling the eye drops, which was then discarded. Resident #9 had been admitted with diagnoses including cerebrovascular accident, anxiety, depression, and diabetes. Resident #4 had been admitted with conditions such as hypertension, heart failure, coronary artery disease, and depression. The failure to follow proper hand hygiene protocols was acknowledged by Nurse #1, who attributed the oversight to being very busy. The Director of Nursing confirmed that Nurse #1 should have adhered to hand hygiene protocols during the medication administration process.
Failure to Offer Pneumococcal Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to offer the Pneumococcal Vaccination to three residents, putting them at risk for developing facility-acquired pneumonia. Resident #5, admitted in September 2023, was over 65 and had their last Pneumococcal Vaccination (PCV13) in July 2018. The facility's records did not indicate that Resident #5 was offered, received, or declined the appropriate Pneumococcal Vaccination upon admission, despite being eligible for an updated dose. Resident #10, admitted in January 2023, was also over 65 and had their last Pneumococcal Vaccination (PCV13) in June 2015. The medical record for Resident #10 similarly failed to show that they were offered, received, or declined a Pneumococcal Vaccination upon admission, even though they were eligible for an updated dose. Resident #18, admitted in July 2023, was over 65 and had their last Pneumococcal Vaccination (PPSV23) in December 2008. The facility's records did not indicate that Resident #18 was offered, received, or declined a Pneumococcal Vaccination upon admission, despite being eligible for an updated dose. The Director of Nursing acknowledged that the facility should have offered the vaccinations to these residents as required.
Inaccurate MDS Coding for Hospice Services
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who was admitted to the facility with Alzheimer's Disease and Intraductal Carcinoma of the breast, was receiving Hospice services as of September 8, 2023. Despite this, the MDS assessments dated December 26, 2023, and March 8, 2024, did not reflect the resident's Hospice status. This discrepancy was identified during an interview with the MDS Coordinator, who acknowledged the incorrect coding of the assessments. The coordinator, responsible for coding MDS information for all residents, had been working at the facility since the end of December 2023.
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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