Royal Meadow View Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Reading, Massachusetts.
- Location
- 134 North Street, North Reading, Massachusetts 01864
- CMS Provider Number
- 225478
- Inspections on file
- 20
- Latest survey
- February 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Royal Meadow View Center during CMS and state inspections, most recent first.
The facility failed to implement the Wound Physician's treatment recommendations for two residents with pressure ulcers, leading to deficiencies in care. One resident with multiple sclerosis and dementia did not receive the recommended dressings and frequency of changes for a Stage IV pressure wound and an unstageable injury. Another resident with a Stage IV sacral ulcer did not receive the recommended superabsorbent gelling fiber and skin prep. The Wound Physician was not notified of these deviations, and the Director of Nursing acknowledged the failure to address and document the treatment recommendations.
The facility failed to store and handle food according to professional standards, with undated food items and personal drinks stored improperly. Additionally, residents were served undercooked unpasteurized eggs, posing a risk for Salmonella infection. The facility's policies on food labeling and dating were not followed, as confirmed by the Food Service Director.
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as staff did not wear precaution gowns during high-contact activities. Additionally, a nurse did not perform proper hand hygiene during wound care for a resident with a stage four pressure ulcer. Shared equipment was also not sanitized between resident uses, as observed with a vitals machine. These lapses were contrary to facility policies and CDC recommendations.
The facility failed to provide a dignified dining experience for residents in the dementia unit, as observed by surveyors. Residents were often left waiting for their meals while their tablemates were already eating, leading to situations where they asked if meals were theirs or took food from others. The DON noted the unpredictability of residents' seating as a challenge, but the repeated delays in serving meals compromised the residents' dining experience.
A resident with cognitive impairment and severe vision issues did not receive the prescribed dysphagia diet and adaptive equipment during meals, as the care plan was not properly implemented. Staff were unaware of the resident's needs, leading to meals being served on regular plates without supervision.
A resident's care plan was not updated to reflect their current eating needs, leading to inappropriate interventions being listed. The resident, who was cognitively intact and did not receive tube feeding, was observed eating while lying flat due to discomfort from elevating the head of the bed. Despite staff awareness of the resident's condition, the care plan was not revised to remove tube feeding interventions and address the resident's preferences.
A resident with multiple sclerosis and dementia did not receive timely wound treatments as ordered by a Wound Physician. Despite the facility's policy requiring adherence to physician orders, there was a 22-day delay in implementing the prescribed care for a non-pressure wound on the resident's shin. Interviews revealed that the Wound Physician expected notification if orders were not followed, and staff were responsible for entering treatment recommendations into the clinical record.
A resident with dementia and Parkinson's disease did not receive necessary assistance with ADLs, including meal supervision and nail care, as outlined in their care plan. Observations showed the resident was left unsupervised during meals, struggling with tasks like opening milk cartons, and had elongated fingernails due to lack of grooming assistance. Communication lapses among staff contributed to the deficiency, as the resident's Kardex did not specify the required level of assistance, and staff were unaware of the supervision needs.
A facility failed to adhere to infection control standards for a resident with an indwelling catheter. The resident's urinary catheter drainage bag and tubing were repeatedly observed in direct contact with the floor, contrary to facility policy. The resident, who was cognitively intact but physically dependent on staff for catheter management, reported frequent issues with the drainage bag being on the floor and leaking. Staff acknowledged the importance of keeping the catheter equipment off the floor to prevent infection.
A resident with dementia and Parkinson's disease was found to have bed rails installed without a prior safety assessment for entrapment risks. The facility's policy requires such assessments upon admission, but it was only completed 20 days later after surveyor intervention. Staff interviews confirmed the oversight, highlighting a lapse in following safety protocols.
The facility failed to limit PRN psychotropic medications to 14 days for a resident with dementia and anxiety disorder, and did not conduct required AIMS assessments for another resident on antipsychotic medication. The oversight in medication management and assessment was acknowledged by the Unit Manager and Director of Nursing.
The facility did not ensure medications were dated once opened, as required by guidelines. During an inspection, a vial of heparin sodium and two vials of insulin glargine were found open and undated in a medication cart. Both Nurse #3 and the DON confirmed that these medications should have been dated due to their shortened expiry dates once opened.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their documented code statuses. One resident was inaccurately documented as DNR by the physician and nurse practitioner, despite records indicating a full code status. Another resident's physician order was documented as full code, while the MOLST indicated DNR/DNI. These inconsistencies were confirmed by the Unit Managers and the DON.
The facility failed to maintain sufficient staffing levels, leading to inadequate care for residents. Observations revealed only one CNA for 18 residents, and interviews confirmed the difficulty in providing care. Two residents reported long wait times and insufficient assistance due to the staffing shortage.
The facility failed to serve food that is palatable, and at a safe and appetizing temperature on two units. Test trays revealed that food temperatures were not within the acceptable range, with items being either warm, lukewarm, or cold, and some having undesirable textures and tastes. The Registered Dietitian confirmed significant temperature drops from the kitchen to the unit, indicating a failure to maintain proper food temperatures during service.
The facility staff failed to ensure an effective QAPI plan was in place, as evidenced by the lack of prioritizing processes, root cause analyses, and tracking of intervention outcomes. Interviews revealed a lack of awareness and communication regarding the water management program and environmental issues, with no QAPI plans addressing staffing and food quality concerns.
The facility failed to ensure proper infection control practices during medication administration and did not complete a risk management assessment for legionella. A nurse did not perform hand hygiene after removing gloves and used a wet blood pressure cuff on a resident. The facility also lacked proper documentation and adherence to its water management policies.
The facility failed to maintain resident rooms in good repair, clean, and homelike on two of three care units. Observations revealed broken furniture, missing tiles, stained toilet seats, exposed cement, large cracks in windows, water stains on ceilings, and peeling wallpaper. The Director of Maintenance admitted to incomplete maintenance requests, and the Administrator was unaware of the issues. Interviews revealed that broken windows identified last year were deemed unsafe but were not replaced.
The facility had a medication error rate of 12.12%, with two nurses making multiple errors in administering medications to two residents. Errors included incorrect timing and dosage, and failure to follow physician's orders and pharmacy recommendations.
The facility failed to conduct comprehensive mattress inspections, neglecting zone 7 and resulting in significant gaps for two residents. One resident had a gap greater than 12 inches between the headboard and mattress, while another had a 5.5-inch gap between the mattress and footboard. The Maintenance Director admitted to not measuring these distances, following a policy that only covered zones one through four.
The facility failed to provide a dignified dining experience for two residents. One resident with severe cognitive impairment and another with hemiparesis were observed being fed by staff members who were standing over them, not at eye level. The DON confirmed that this practice is unacceptable and violates the residents' right to dignity.
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. There was no documentation of a pre-restraining assessment, a physician's order, or a care plan intervention for the use of these pillows as restraints.
The facility failed to develop and implement a baseline care plan within 48 hours for a resident at risk for elopement. Despite the resident's history of exit-seeking behavior and wandering, care plans were delayed, and an inaccurate elopement assessment was conducted. Staff interviews confirmed the oversight and the necessity for a timely care plan.
The facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, but the medical record did not indicate a care plan addressing this issue.
A resident with dementia and essential hypertension was found with unswallowed medication due to a nurse not following the facility's policy of staying with the resident until all medication was swallowed. The nurse assumed the resident had taken the medication, but further inspection revealed otherwise.
The facility failed to provide necessary services for a resident with limited English proficiency (LEP) to effectively communicate needs. Despite the resident's dependence on staff for daily activities and a care plan requiring an interpreter and communication board, these tools were not consistently available. Staff acknowledged the communication barrier and the inadequacy of the provided resources.
The facility failed to supervise a resident with Alzheimer's and epilepsy during meals, despite the care plan indicating the need for supervision. The resident was observed eating alone multiple times, leading to incidents of profuse coughing and near choking. Staff were present nearby but did not provide the necessary assistance.
A resident experienced significant weight loss due to the facility's failure to implement the RD's recommendation to increase the frequency of nutritional supplements. Despite documented recommendations, the necessary physician orders were not placed, resulting in continued inadequate supplementation.
The facility failed to provide trauma-informed care for two residents with PTSD by not conducting trauma assessments per policy and not developing comprehensive care plans that include triggers for re-traumatization. One resident had intact cognition, while the other had moderate cognitive impairment. The Social Worker acknowledged the need for better documentation of PTSD triggers and care plans.
A resident with celiac disease was served a meal containing gluten despite their dietary restrictions. The cook added wheat-containing gravy to the resident's meal, contrary to the facility's policy and the resident's meal ticket instructions.
The facility failed to handle food in accordance with professional standards, with staff repeatedly touching resident food directly with their bare hands during meal set-up and feeding assistance. Observations during breakfast and lunch revealed multiple instances of non-compliance with the facility's policy, which mandates the use of gloves when handling food.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident #7, who was admitted with multiple sclerosis and dementia, had a Stage IV pressure wound on the left ischium and an unstageable pressure injury on the lower sacrum. The facility did not implement the treatment recommendations made by the consultant Wound Physician, which included the use of specific dressings such as Mesalt, Plurogel, and superabsorbent gelling fiber. Instead, the facility continued using Santyl and Mupirocin ointments, which were not recommended by the Wound Physician. The orders also failed to follow the recommended frequency of dressing changes, which was once daily, and did not include the use of superabsorbent gelling fiber as indicated by the Wound Physician. Resident #26, who was admitted with multiple sclerosis and failure to thrive, had a Stage IV pressure ulcer on the sacrum. The facility did not follow the Wound Physician's recommendations for dressing treatment, which included the use of Mupirocin, Alginate calcium, Santyl, and superabsorbent gelling fiber with silicone border. The facility's orders included a dry protective dressing instead of the recommended superabsorbent gelling fiber, and the application of skin prep to the peri-wound was not implemented. The Wound Nurse responsible for transcribing the physician's orders admitted to not implementing the Wound Physician's recommendations and did not notify the Wound Physician of the changes made to the treatment plan. Interviews with the Wound Physician and the Director of Nursing revealed that the facility did not notify the Wound Physician when his treatment orders were not being implemented. The Wound Physician expected to be informed if his recommendations were not followed, and the Director of Nursing stated that all wound consultant treatment recommendations should be addressed and documented if not implemented. The failure to implement the Wound Physician's recommendations and the lack of communication regarding these changes contributed to the deficiencies in pressure ulcer care for the residents.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The surveyor noted several instances of improper food storage and handling, including undated deli ham, chicken, biscuit dough, and hotdogs in the walk-in refrigerator. Additionally, there were open containers of apple juice and personal items like kombucha stored near resident food. In the unit kitchenettes, open and undated bottles of orange and apple juice were found, along with a sandwich past its use-by date. These observations indicate a lack of compliance with the facility's policy on labeling and dating food items, which is essential for ensuring food safety and minimizing waste. Furthermore, the facility served undercooked unpasteurized eggs to residents, which poses a significant risk for Salmonella infection, especially for the elderly and immunocompromised individuals. During the survey, it was observed that residents were served fried eggs with runny yolks, and the eggs used were not confirmed to be pasteurized. The Food Service Director confirmed that unpasteurized eggs should be cooked until the yolk is firm, and the Corporate Food Service Director acknowledged the lack of proper labeling and dating of food items, as well as the inappropriate storage of personal drinks in the facility's freezer.
Infection Control Deficiencies in LTC Facility
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Summary
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as required by their care plans and facility policy. Resident #76, who was cognitively intact, was observed being washed by a CNA who wore gloves but not a precaution gown, despite a sign indicating the need for enhanced barrier precautions. Similarly, Resident #24, who had severe cognitive impairment, was observed having bed linens changed by a CNA who also wore gloves but not a precaution gown. Interviews with the Unit Manager and Director of Nursing confirmed that staff were required to wear both gloves and a precaution gown during high-contact activities for residents on enhanced barrier precautions. The facility also failed to ensure proper hand hygiene during wound care for Resident #26, who had a stage four pressure ulcer. A wound nurse was observed changing the resident's dressing without sanitizing her hands after removing soiled gloves and before applying new ones. The nurse acknowledged the lapse in hand hygiene during an interview, which was contrary to the facility's hand hygiene policy that requires sanitizing hands before and after using personal protective equipment. Additionally, the facility did not sanitize shared resident equipment between uses. A nurse was observed using a vitals machine on two different residents without disinfecting it in between. The nurse admitted to not disinfecting the equipment, and the Director of Nursing was unaware of the requirement to sanitize shared equipment between resident uses, as per CDC recommendations. This oversight in infection control practices was noted during the surveyor's observations.
Failure to Provide Dignified Dining Experience in Dementia Unit
Penalty
Summary
The facility failed to provide a dignified dining experience for residents residing on the dementia unit, as observed by surveyors. On multiple occasions, residents were observed waiting for their meals while their tablemates were already eating. For instance, during breakfast on the View Unit, some residents were served while others watched, leading to situations where residents asked if the meals being served were theirs or even took food from their tablemates. This pattern was consistent across different meal times, with significant delays between the first and last residents being served at the same table. The Director of Nursing acknowledged the issue, noting that the unpredictability of residents' seating arrangements contributed to the difficulty in serving meals simultaneously. Despite this acknowledgment, the observations clearly indicated a failure to ensure that all residents were served their meals in a timely and dignified manner, which is a fundamental right of the residents. The deficiency was evident in the repeated instances of residents having to wait and watch others eat, which compromised their dining experience.
Failure to Implement Person-Centered Care Plan for Resident
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Summary
The facility failed to develop and implement a person-centered care plan for a resident with paranoid schizophrenia, legal blindness, and malnutrition. The resident was admitted in March 2019 and had a recent Minimum Data Set (MDS) assessment indicating moderate cognitive impairment and severely impaired vision. Despite physician's orders for a dysphagia advanced/ground texture diet and the use of a lip plate to aid in eating, the resident was observed eating meals on a regular plate without staff supervision or assistance on multiple occasions. The resident's care plan did not reflect the need for an altered diet or the use of adaptive equipment, and staff were unaware of these requirements. The Unit Manager and Director of Nurses acknowledged the oversight, indicating a lack of adherence to the facility's policy on comprehensive person-centered care plans. This failure to implement the care plan as prescribed resulted in the resident not receiving the necessary supervision and adaptive equipment during meals.
Failure to Revise Care Plan for Resident's Eating Needs
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Summary
The facility failed to revise the comprehensive care plan for a resident, specifically regarding tube feeding and risk for choking, after two quarterly assessments. The resident, who was cognitively intact, required setup assistance with eating and did not receive tube feeding, as indicated in the Minimum Data Set (MDS) assessments. Despite this, the care plan included interventions for tube feeding and elevating the head of the bed, which were not applicable to the resident's current condition. Observations revealed that the resident was lying flat in bed while eating, which contradicted the care plan's interventions. The resident expressed discomfort with elevating the head of the bed due to pain from a pressure sore and arthritis, preferring to eat while lying flat. Staff interviews confirmed that the resident had not received tube feeding and only ate by mouth. The interdisciplinary team (IDT) failed to update the care plan to reflect the resident's current needs and preferences, despite being aware of the resident's condition and preferences for at least six months. The care plan meetings, which should have included revisions to the care plan, did not address the resident's inability to tolerate head elevation or the absence of tube feeding. Various staff members, including the Unit Manager, Dietitian, Occupational Therapist, and Speech Therapist, acknowledged that the care plan interventions were inappropriate and should have been revised. The Director of Nursing also confirmed that the care plan should have been updated to include the resident's noncompliance with head elevation during meals.
Failure to Implement Wound Treatments as Ordered
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Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with multiple sclerosis and dementia. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had two existing pressure areas. The deficiency was identified when the facility did not implement wound treatments as ordered by the consultant Wound Physician for a non-pressure wound on the resident's left upper shin. The Wound Physician had documented treatment recommendations on multiple occasions, but the facility did not begin implementing these treatments until 22 days after the initial order. The facility's policy on wound treatment management required that wound treatments be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Despite this policy, the treatment administration records showed a significant delay in the implementation of the prescribed wound care. Interviews with the Wound Physician and Wound Nurse revealed that the physician expected to be notified if his orders were not being implemented, and the nurse confirmed that staff were responsible for inputting the physician's treatment recommendations into the clinical record. This lapse in care highlights a failure in the facility's processes to ensure timely and accurate implementation of physician orders.
Failure to Provide ADL Assistance for Resident with Dementia and Parkinson's
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Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with dementia and Parkinson's disease, identified as Resident #55. The resident required supervision or touching assistance for eating and substantial assistance with personal hygiene, as indicated in their care plan and occupational therapy evaluation. However, observations revealed that the resident was left unsupervised during meals on multiple occasions, struggling to open milk cartons and spilling milk on themselves, without any staff present to assist. Additionally, the facility did not provide adequate nail care for the resident. Observations noted that the resident's fingernails were elongated and protruding, indicating a lack of regular grooming assistance. Interviews with staff confirmed that the resident typically allows staff to assist with grooming, and the Director of Nursing stated that staff should offer assistance with nail care and document any refusals, which was not done in this case. The deficiency was further compounded by communication lapses among staff. The Director of Rehab expected staff to supervise the resident during meals, but the Unit Manager was unaware of this requirement, and the resident's Kardex did not specify the level of assistance needed for eating. This lack of communication and documentation led to the resident not receiving the necessary care and supervision as outlined in their care plan.
Failure to Maintain Infection Control for Urinary Catheter Care
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Summary
The facility failed to maintain professional standards in managing and caring for urinary catheter devices for a resident with an indwelling catheter. The resident, who was cognitively intact and required assistance for mobility and toileting, had a urinary catheter drainage bag and tubing that were repeatedly observed to be in direct contact with the floor. This was contrary to the facility's policy, which specified that catheter tubing and drainage bags should be kept off the floor to prevent infection. The resident reported that the drainage bag was often on the floor and sometimes leaked, and stated that they were dependent on staff for catheter management due to physical limitations. Multiple observations by the surveyor confirmed that the urinary drainage bag and tubing were not properly secured and were in contact with the floor on several occasions. Staff members, including a CNA and the Unit Manager, acknowledged that the drainage bag and tubing should not touch the floor due to infection control concerns. The Director of Nursing also confirmed that the drainage bags and tubing should never be directly touching the floor, indicating a lapse in adherence to infection control protocols.
Failure to Assess Bed Rail Safety for Resident
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for a resident, identified as Resident #55, who was admitted with diagnoses of dementia and Parkinson's disease. The deficiency was identified when it was observed that the resident's bed was equipped with side rails on both sides without a prior assessment for risk of entrapment. The facility's policy requires an interdisciplinary team to assess the resident's sleeping environment, including the use of side rails, to prevent injuries or deaths from bed-related equipment. However, this assessment was not completed for Resident #55 until 20 days after admission, following the surveyor's intervention. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, revealed that side rail assessments should be completed upon admission and before the use of side rails. The Director of Maintenance confirmed that while the maintenance department assesses beds for entrapment risks annually and upon new admissions, there was no evidence of such an assessment for Resident #55's bed after their admission. This oversight led to the deficiency being cited during the survey.
Failure to Limit PRN Psychotropic Medications and Conduct AIMS Assessments
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications and were properly assessed for adverse reactions to psychotropic medications. For one resident, the facility did not limit the use of PRN psychotropic medications to 14 days as required by their policy. The resident, who was admitted with diagnoses including unspecified dementia with agitation and anxiety disorder, received doses of lorazepam without a stop date, contrary to the facility's policy. The Unit Manager acknowledged the oversight and indicated the need to discuss scheduling the medication with the physician. Another resident, admitted with diagnoses including heart failure, Alzheimer's Disease, and chronic kidney disease, did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed as required. The resident was receiving antipsychotic medication, and the most recent AIMS assessment was completed over a year ago, despite the facility's policy requiring such assessments quarterly or with significant changes. The Director of Nursing confirmed the expectation for AIMS assessments to be completed every six months for residents on antipsychotic medications.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to comply with State and Federal requirements for the storage of drugs and biologicals, as observed by surveyors. During an inspection of the Court unit medication cart, it was found that one vial of heparin sodium injection solution and two vials of insulin glargine subcutaneous solution were open and undated. This is contrary to the manufacturer's guidelines, which require these medications to be dated once opened due to their shortened expiry dates. Nurse #3 confirmed that the medications should have been dated when opened, and the Director of Nursing also acknowledged this requirement during an interview.
Inaccurate Documentation of Code Status for Residents
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Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in their documented code statuses. For one resident, the physician and nurse practitioner inaccurately documented the resident's code status as Do Not Resuscitate (DNR) when the resident's Medical Orders about Life-Sustaining Treatment (MOLST) and other records indicated a full code status, meaning resuscitation should be attempted. This inconsistency was confirmed during an interview with the Unit Manager, who acknowledged the error in the documentation by the physician and nurse practitioner. For another resident, the facility inaccurately documented the resident's physician's order as a full code, while the resident's MOLST indicated a DNR and Do Not Intubate (DNI) status. This discrepancy was identified during a review of the resident's records and confirmed by the Unit Manager, who noted that the MOLST should match the physician's order to ensure clarity for the nursing staff. The Director of Nursing also confirmed that the MOLST should align with the physician's order, highlighting the facility's failure to maintain consistent and accurate medical records.
Facility Fails to Maintain Sufficient Staffing Levels
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Summary
The facility failed to maintain sufficient staffing levels to adequately meet residents' care needs. On 2/27/24, the surveyor observed only one CNA working on the Court Unit, which housed 18 residents. The Director of Nursing acknowledged that staffing has been an ongoing challenge. The facility assessment indicated that 33 full-time equivalent CNAs were needed daily, but actual staffing ranged from 18 to 24 CNAs per day. Interviews with staff confirmed the difficulty in providing adequate care due to insufficient staffing levels. The Administrator admitted to being aware of the staffing issues but had not implemented any new initiatives to enhance CNA recruitment. Two residents, one admitted in November 2023 with anxiety and depression and another admitted in September 2023 with cancer and traumatic brain injury, reported not receiving timely care due to the staffing shortage. Both residents, who were cognitively intact, expressed frustration over long wait times for assistance and inadequate care. One resident mentioned having to wheel themselves into the hallway to find help, while the other reported not receiving showers as often as desired. The Director of Nursing also noted that the acuity levels of residents had increased over the past several months, further exacerbating the staffing issue.
Failure to Serve Food at Safe and Appetizing Temperatures
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Summary
The facility failed to serve food that is palatable, and at a safe and appetizing temperature on two out of two units. During a group meeting, all 12 participants reported that the food was not hot when served. Test trays conducted on the Meadows Unit and the Dementia Unit revealed that the food temperatures were not within the acceptable range. Specifically, on the Meadows Unit, the meatloaf was 90 degrees Fahrenheit, green beans were 80 degrees Fahrenheit, potatoes were 84 degrees Fahrenheit, apple pie was 60 degrees Fahrenheit, milk was 40 degrees Fahrenheit, and apple juice was 50 degrees Fahrenheit. On the Dementia Unit, the meatloaf was 135.1 degrees Fahrenheit, green beans were 123.4 degrees Fahrenheit, potatoes were 132.6 degrees Fahrenheit, apple pie was 52.3 degrees Fahrenheit, milk was 55 degrees Fahrenheit, and apple juice was 54.4 degrees Fahrenheit. The food items were described as either warm, lukewarm, or cold, and some had undesirable textures and tastes, such as being bland, grainy, gritty, or gummy. The Registered Dietitian (RD) confirmed that the facility conducts periodic test trays and provided results from a previous test tray conducted on 12/5/23. The results showed significant temperature drops from the kitchen to the unit, with hot foods falling below the acceptable range of greater than 120 degrees Fahrenheit and cold foods exceeding the acceptable range of less than 50 degrees Fahrenheit. For example, a hot dog measured 140 degrees Fahrenheit in the kitchen but only 110 degrees Fahrenheit on the unit, and milk measured 40 degrees Fahrenheit in the kitchen but 60 degrees Fahrenheit on the unit. The RD stated that the metrics used to evaluate test trays are outlined on the test-tray form, indicating a failure to maintain proper food temperatures during service.
Ineffective QAPI Plan and Lack of Performance Improvement
Penalty
Summary
The facility staff failed to ensure an effective Quality Assurance Performance Improvement (QAPI) plan was in place. The review of the QAPI meeting minutes for 2023 revealed that the facility did not implement a prioritizing process, complete root cause analyses for identified problems, or track outcomes for interventions to determine their effectiveness. Specifically, the December 2023 QAPI meeting minutes did not show that performance improvement plans were implemented for known areas of concern, including adequate staffing, food quality, environmental concerns, and the continuation of the water management program. Interviews with the Maintenance Director and the Administrator highlighted a lack of awareness and communication regarding the water management program and environmental issues. The Maintenance Director was unable to speak to the water management program and only provided a risk assessment for legionella on the day of the interview. The Administrator admitted to relying on the Maintenance Director for updates on environmental issues and was unaware of the water management program issues. Additionally, the Administrator acknowledged concerns with staffing and food quality but confirmed that no QAPI plans were in place to address these issues.
Infection Control and Legionella Risk Management Deficiencies
Penalty
Summary
The facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, during a medication pass, a nurse did not perform hand hygiene after removing gloves and before administering medication to a resident. The nurse also used a wet blood pressure cuff on the resident and stacked medication cups, which are not clean on the bottom, inside one another. The Director of Nurses confirmed that the nurse should have used hand sanitizer before and after removing gloves and before administering medication, and should have waited for the disinfectant to dry before using the equipment. Additionally, the facility failed to complete a risk management assessment for the possible development and spread of legionella. The Maintenance Director was unable to confirm if the facility had a water management program or how the facility assesses the risk of legionella. The risk assessment was only completed during the survey, and the Administrator could not find a previously completed risk assessment, indicating a lack of proper documentation and adherence to the facility's water management policies.
Facility Fails to Maintain Safe and Homelike Environment
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Summary
The facility failed to ensure resident rooms were maintained in good repair, clean, and homelike on two of three resident care units. Observations on the Meadow unit revealed multiple deficiencies, including nightstands with dark scuff marks, chipped paint, and bubbling paint on pull-out drawers. Bathrooms had dark scuff marks, chipped paint, and discoloration. Several rooms had broken furniture, missing tiles, stained toilet seats, and exposed cement. Additionally, there were large cracks in windows, water stains on ceilings, and peeling wallpaper. The hallways on the Meadow unit also had black scuff marks on the walls, and a large water stain was observed on the ceiling above the water fountain entering the unit. On the View unit, similar issues were observed. A water fountain was attached to the wall with visible cracked plaster and chipped paint. Resident rooms had broken furniture, holes in doors, peeling wallpaper, and stained floor tiles. The Director of Maintenance (DOM) admitted to conducting monthly environmental rounds but failed to document and complete maintenance requests. The DOM also mentioned that only a few staff members were trained to use the online reporting system for tracking building issues. The Administrator was unaware of the environmental issues and relied on the DOM to inform her of any problems. Interviews with the Regional Director of Maintenance (RDOM) and the Director of Nurses (DON) revealed that broken windows identified last year were deemed unsafe but were not replaced. The RDOM did not follow up to ensure the windows were fixed, and the DON emphasized that broken windows are a safety concern for residents and should be addressed immediately. The facility's failure to maintain a safe, clean, and homelike environment for residents was evident in the numerous deficiencies observed and the lack of timely corrective actions.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5%, with two nurses making 4 errors out of 33 opportunities, resulting in a medication error rate of 12.12%. For Resident #23, Nurse #5 administered Glipizide within 30 minutes of the resident eating breakfast, contrary to the physician's order to administer the medication 30 minutes before meals. Nurse #5 acknowledged the mistake during an interview, stating that she should have followed the order to wait 30 minutes before meals. For Resident #28, Nurse #2 made multiple errors while administering medications. The nurse did not give the correct Vitamin D3 + Calcium tablet and did not administer the correct dose of Vitamin B12. Additionally, Nurse #2 administered Levothyroxine with Iron and Calcium, which should have been separated by 4 hours as per the medication card instructions. Both the unit manager and the Director of Nursing confirmed that the medications should have been administered as per the physician's orders and pharmacy recommendations.
Failure to Ensure Comprehensive Mattress Inspections
Penalty
Summary
The facility failed to ensure a comprehensive inspection system for resident mattresses, specifically neglecting to evaluate zone 7 for potential entrapment hazards. The facility's policy only covered zones one through four, which led to the oversight of significant gaps in zone 7 for two residents. Resident #67, diagnosed with PTSD and major depressive disorder, was observed with a gap greater than 12 inches between the headboard and the mattress. Resident #67 also mentioned that the mattress was too short. Resident #72, who had severe cognitive impairment and was dependent on staff for daily living due to a stroke, was found with a 5.5-inch gap between the mattress and the footboard. A gap filler had been placed but had fallen below the mattress, rendering it ineffective. During an interview, the Maintenance Director admitted to not measuring the distance from the mattress to the headboard or footboard, following the facility's policy that only addressed zones one through four. This failure to adhere to comprehensive guidelines for bed safety, as outlined by the FDA's Hospital Bed System Dimensional and Assessment Guidance, resulted in the potential hazard of entrapment for the residents. The facility's policy did not align with the recommended safety measures, leading to the identified deficiencies.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, Resident #80 and Resident #85. Resident #80, who has severe cognitive impairment due to Alzheimer's Disease and is dependent on staff for partial/moderate feeding assistance, was observed being fed by a staff member who was standing over them, not at eye level. This observation was made in the dining room of the View unit. Similarly, Resident #85, who has diagnoses including stroke and hemiparesis or hemiplegia and is dependent on staff for substantial/maximum feeding assistance, was observed being fed by a staff member who was also standing over them and not at eye level in their room. The resident's bed was not raised during the feeding assistance. During an interview, the Director of Nursing (DON) confirmed that staff should always be seated and at eye level with a resident while providing feeding assistance. The DON acknowledged that it would be unacceptable for staff to stand over a resident while providing feeding assistance, as this would be a dignity issue. The facility's policy on Resident Rights also indicates that residents have the right to be treated with respect and dignity.
Failure to Assess and Document Use of Pillows as Restraints
Penalty
Summary
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, which were intended to prevent the resident from falling out of bed. However, there was no documentation of a pre-restraining assessment, a physician's order, or a care plan intervention for the use of these pillows as restraints. Additionally, the medical record did not indicate any restraint elimination assessment to determine the least restrictive method for the least amount of time. Interviews with staff revealed that the pillows were placed to prevent the resident from falling out of bed due to restlessness and attempts to get out of bed, particularly at night. The Director of Nursing confirmed that the use of pillows under the fitted sheet would constitute a restraint if the resident was capable of moving in bed and acknowledged that a pre-restraining assessment should have been completed. The facility's failure to follow its own policy on the use of restraints led to this deficiency.
Failure to Develop Baseline Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was at risk for elopement. The resident, admitted with a diagnosis of dementia, had a history of exit-seeking behavior and a previous elopement incident. Despite this, the care plans were not initiated until six days after admission. The elopement assessment conducted was inaccurate, stating that the resident had not exhibited wandering behaviors in the last 60 days and was not at risk for elopement, contrary to the resident's documented history and observed behaviors upon admission. Interviews with facility staff, including a CNA, a nurse, the unit manager, and the DON, confirmed that the resident was known to be at risk for elopement and that the elopement assessment was inaccurate. The staff acknowledged that a baseline care plan specific to wandering and elopement should have been developed within 48 hours of admission. The facility's policy requires that baseline care plans be developed within 48 hours to address immediate care and safety needs, which was not adhered to in this case.
Failure to Develop Care Plan for Potential Restraint
Penalty
Summary
The facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for a resident with severe cognitive impairment and left-sided hemiplegia. The resident was observed multiple times with pillows under the fitted sheet on both sides of the bed, which the Director of Nursing acknowledged could constitute a restraint if the resident is capable of moving in bed. Despite these observations, the medical record did not indicate the development of a care plan addressing the use of these pillows as restraints.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of practice for medication administration for a resident with dementia and essential hypertension. The resident, who had severely impaired cognition, was observed alone in their room with a pill in their hand and two additional pills in a cup of water. The nurse responsible for administering the medication did not stay with the resident to ensure that the medication was swallowed, as required by the facility's policy. The nurse admitted to thinking that the resident had swallowed the pills, but upon further inspection, it was found that the resident had not. The Director of Nursing confirmed that it is the facility's expectation for nurses to stay with residents until all medication is swallowed and to check for any pocketed medication. This lapse in procedure led to the resident not taking their prescribed hypertension medications properly.
Failure to Provide Adequate Communication Services for LEP Resident
Penalty
Summary
The facility failed to provide necessary services to ensure a resident with limited English proficiency (LEP) could effectively communicate his/her needs. The resident, who was admitted with diagnoses including stroke and hemiparesis, was dependent on staff for various activities of daily living and required an interpreter. Despite this, the facility did not provide adequate translation services or communication tools, such as a communication board, to facilitate interaction between the resident and staff. The resident's preferred language was Russian, and the care plan indicated the use of a translator, specifically the resident's son, and a communication board, neither of which were consistently available or utilized by the staff during the surveyor's observations. During multiple observations, the surveyor noted that the resident's son, who was identified as the primary translator, was not present, and there was no communication board in the resident's room. Staff members attempted to communicate with the resident in English, which the resident did not understand. The resident's room contained English-language materials, such as a TV and magazines, which were not useful for the resident. Staff members, including CNAs and nurses, acknowledged the communication barrier and the absence of appropriate tools to facilitate communication. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed that the interventions listed in the resident's communication care plan were not being implemented. The DON and other staff members admitted that the scrap piece of paper with a few translated words was inadequate for meeting the resident's communication needs. The lack of a comprehensive communication board and the reliance on the resident's son, who was not always present, contributed to the resident's inability to effectively communicate his/her needs, leading to a deficiency in the care provided by the facility.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to ensure supervision with meals for Resident #44, who has diagnoses including Alzheimer's disease and epilepsy, and is noted to have moderately impaired cognition. The resident's care plan indicated the need for supervision during meals, but this was not consistently provided. On multiple occasions, the resident was observed eating alone in their room without staff supervision, leading to incidents of profuse coughing and near choking. Despite the presence of staff nearby, no immediate assistance was provided to the resident during these episodes. On one occasion, the surveyor observed Resident #44 coughing profusely while eating lunch alone in their room. Although staff were present in the hallway and a nurse was feeding another resident across the hall, no one responded to the resident's distress. The resident later expressed fear about the choking incident. Similar observations were made during breakfast the following day, where the resident was again left unsupervised and began coughing on a bite of food. The surveyor had to intervene as no staff were present to assist. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan requirements. A nurse admitted to not being informed about the resident's need for meal supervision, and a CNA acknowledged that supervision should involve staying with the resident for the entire meal. The Nurse Unit Manager and the Director of Nursing confirmed that the resident should be supervised during meals, whether in the dining room or in their room, but this protocol was not followed, leading to repeated instances of the resident being left unsupervised during meals.
Failure to Implement RD's Nutritional Supplement Recommendations
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident, identified as Resident #13, who experienced significant weight loss over several months. Despite recommendations from the Registered Dietitian (RD) to increase the frequency of nutritional supplements from twice a day to three times a day, these recommendations were not implemented. The RD's recommendations were communicated verbally to nursing staff and documented, but the necessary physician orders to increase the supplement frequency were not placed. This oversight resulted in Resident #13 continuing to receive the supplement only twice a day, leading to further weight loss. Resident #13, who was admitted with diagnoses including dementia and adult failure to thrive, experienced a severe and clinically significant weight loss over several months. The weight report indicated multiple instances of significant weight loss, including an 11.4-pound loss in one month and a 16.3-pound loss in another month. Despite the RD's recommendations documented on 9/21/23 and 11/9/23, the frequency of the nutritional supplement was not increased. Interviews with the RD and Unit Manager confirmed that the recommendation should have been implemented, but an error occurred when the order was re-entered incorrectly on 9/26/23.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure that residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility did not conduct an assessment for trauma per the facility policy and did not develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two residents. Resident #67, admitted in June 2021 with diagnoses including PTSD and major depressive disorder, had a care plan that failed to indicate triggers for re-traumatization and how the resident exhibits an activation of PTSD when it occurs. The Minimum Data Set (MDS) assessment indicated that Resident #67 had intact cognition with a score of 15 out of 15 on the Brief Interview for Mental Status exam. Similarly, Resident #24, admitted in September 2022 with a diagnosis of PTSD, had a care plan that did not indicate triggers for re-traumatization and how the resident exhibits an activation of PTSD when it occurs. The most recent MDS indicated that Resident #24 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. During an interview, the Social Worker (SW) acknowledged that she tries to find out the resident's triggers through conversation and observation but admitted that the PTSD triggers should be documented in the care plan along with how the resident exhibits PTSD and how to help during a triggered episode. The SW also mentioned that she puts a PTSD care plan in the resident's medical record when she sees the PTSD diagnosis, and her consultant reviews the care plans periodically.
Failure to Accommodate Gluten Intolerance for Resident with Celiac Disease
Penalty
Summary
The facility failed to accommodate a food intolerance for a resident with celiac disease, resulting in the resident being served gluten-containing food. The resident, who was admitted with a diagnosis of celiac disease and required a gluten-free diet, was observed being served a meal with gravy containing wheat. This was despite the resident's meal ticket indicating a gluten-free requirement and the facility's policy to offer appropriate substitutions for food intolerances. During the observation, the cook prepared a meal with a gluten-free roll and beef patty but added gravy made from a mix containing wheat. The Food Service Director confirmed that the gravy should not have been served to the resident. The Registered Dietitian also stated that residents with celiac disease should not consume gluten as it could lead to intestinal damage. The incident highlights a failure in the facility's adherence to dietary restrictions for residents with specific food intolerances.
Failure to Adhere to Food Handling Standards
Penalty
Summary
The facility failed to handle food in accordance with professional standards for food service safety, specifically by allowing nursing staff to touch resident food directly with their bare hands during meal set-up and feeding assistance in the dining room of the View unit. Observations made by the surveyor during breakfast and lunch meals on 2/27/24 revealed multiple instances where staff members picked up residents' toast, opened milk containers, and handled sandwiches and hot dogs with their bare hands before serving them to the residents. These actions were in direct violation of the facility's policy, which prohibits bare hand contact with food and mandates the use of gloves when handling food directly. Interviews conducted with the Food Service Director and the Director of Nursing confirmed that staff should not be touching ready-to-eat food with their bare hands and that gloves should be used. Despite this policy, the surveyor observed repeated instances of non-compliance, indicating a systemic issue with food handling practices in the facility. No specific details about the medical history or condition of the residents involved were provided in the report.
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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